Oncology Part II Flashcards by Silver Gold

Trastuzumab (Herceptin)

Mechanism

Binds to human epidermal growth factor receptor 2 (HER2)

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Trastuzumab (Herceptin)

Key Safety Concerns

Cardiotoxicity (eg, cardiomyopathy)

Monitor LVEF before & after treatment

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Bevacizumab (Avastin)

Mechanism

Binds to vascular endothelial growth factor (VEGF)

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Bevacizumab (Avastin

Key Safety Concerns

Impaired wound healing
* Avoid for 28 days before or after surgery

Thromboembolic events

Hemorrhage/fatal bleeding

Gl perforation

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Programmed Death Receptor-1 (PD-1) inhibitors

Drugs

Pembrolizumab (Keytruda)

Nivolumab (Opdivo)

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Cytotoxic T-Lymphocyte Antigen-4 (CTLA-4) Inhibitor

Drug

Ipilumumab (Yervoy)

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Key Safety Concerns

PD-1 & CTLA-4

Immune-mediated toxicities (eg, endocrinopathies, colitis, hepatotoxicity)

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Identifying Prostate Cancer

Abnormal DRE + PSA > 10 ng/mL

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Gonadotropin-releasing hormone (GnRH) agonists

Common drugs

Leuprolide (Lupron Depot)

Goserelin (Zoladex)

Histrelin (Supprelin LA)
Triptorelin (Trelstar)

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Gonadotropin-releasing hormone (GnRH) agonists

Safety concerns

↓ bone density
* Prevent with calcium & vitamin D

Tumor flare
Give with antiandrogen
Hot flashes
Impotence, gynecomastia
Bone pain
QT prolongation

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Gonadotropin-releasing hormone (GnRH) antagonists

Common drugs

Degarelix (Firmagon)

Relugolix (Orgovyx)

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Gonadotropin-releasing hormone (GnRH) antagonists

Safety concerns

Hot flashes

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Antiandrogens

Common drugs

Bicalutamide (Casodex)

Flutamide

Nilutamide (Nilandron)

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Antiandrogens

Safety concerns

Hot flashes

Gynecomastia

Hepatotoxicity

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Vinca Alkaloids

Drugs

Vincristine

Vinblastine

Vinorelbine

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Vinca Alkaloids

Side Effects

Peripheral sensory neuropathy (paresthesias)

Autonomic neuropathy (gastroparesis, constipation)

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Vinca Alkaloids

Peripheral neuropathy

Monitor S/Sx (eg, numbness, paresthesia, pain)

Prevention: Limit single vincristine doses to 2 mg

Tx: Neuropathic pain medications (eg, gabapentin, duloxetine)

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Vinca Alkaloids

Autonomic neuropathy

Monitor S/Sx (eg, Bowel movement frequency)

Prevention & Tx: Symptomatic care (eg, diet modifications, laxatives)

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Vinca Alkaloids

Administration

Only IV

Prepare in a small IV bag

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Tretinoin

Safety Concern

Differentiation syndrome (fever, dyspnea, pleural effusion)

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Tretinoin

Management

Systemic steroids (eg, dexamethasone)

Interrupt therapy

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Arsenic trioxide

Safety Concern

QT prolongation

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Arsenic trioxide

Management

Maintain K > 4 and Mg > 1.8 mEq/L

Avoid QT-prolonging drugs

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Bleomycin

Safety Concern

Pulmonary toxicity (eg, pulmonary fibrosis)

Hypersensitivity reactions

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# Bleomycin Management

Limit lifetime cumulative dose to 400 units Test dose and/or premedicate

# Bortezomib & Carfilzomib Safety Concern | Proteasome Inhibitors

Herpes reactivation

# Bortezomib & Carfilzomib Management | Proteasome Inhibitors

Antiviral agents (eg, acyclovir, valacyclovir)

Immunomodulators Meds

Lenalidomide (Revlimid) Pomalidomid (Pomlyst) Thalidomide (Thalomid)

# Lenalidomide, Pomalidomid, & Thalidomide Safety Concern | Immunomodulators

Sever birth defects (need 2 negative pregnancy tests) Thrombosis (DVT/PE)

# Lenalidomide, Pomalidomid, & Thalidomide Management | Immunomodulators

REMS program 2 form of contraception or abstain from sex PPx anticoagulation

# Pegaspargase Safety Concerns | Modified from of L-asparaginase conjugated w/ polyethylene glycol

Hypersensitivity Reactions

# Pegaspargase Management | Modified from of L-asparaginase conjugated w/ polyethylene glycol

Premedication w/ APAP, diphenhydramine & an H2RA

What does rituximab target? A. EGFR B. VEGF C. CD20 D. HER2 E. PD-1

CD20 | Brand (Rituxan) ## Footnote Rituximab binds to the CD-20 antigen on the B-cells, so patients must be CD20 positive in order to use rituximab. CD refers to the Leukocyte Cluster of Differentiation antigens.

On day 5 of the chemotherapeutic regimen, he complains of tingling, numbness and pain in his fingers. Which of his chemotherapeutic medications is most likely causing these symptoms? A. Rituximab B. Cyclophosphamide C. Doxorubicin D. Vincristine E. Prednisone

Vincristine ## Footnote Vincristine is notable for causing peripheral neuropathies.

Which agents are cell cycle independent?

Alkylating agents (eg, cyclophosphamide) Anthracyclines (eg, doxorubicin) Platinum compounds (eg, cisplatin)

Which agents work on the S phase?

Antimetabolites (eg, methotrexate) Topoisomerase I inhibitors (eg, irinotecan)

Which agents works on the G2 phase?

Etoposide Bleomycin

Which agents works on the M phase?

Taxanes Vinca alkaloids

# Pyrimidine analog antimetabolites MOA

S phase Incoporates into DNA by interfering w/ certain nucleotides in RNA & DNA Flurorouracil inhibits thymidylate synthase

# Pyrimidine analog antimetabolites Drugs

Fluoro**uracil** Capecitabine ## Footnote Capecitabine is converted into Fluorouracil

# Pyrimidine analog antimetabolites What is given w/ fluorouracil to ↑ efficacy?

Leucovorin or Levoleucovorin

# Pyrimidine analog antimetabolites Adverse Effects

Hand-Foot Syndrome (Palmar-Plantar Erythrodysesthesia) GI Toxicities: Diarrhea, mucositis Severe toxicities ↑ w/ dihydropyrimidine dehydrogenase (DPD) deficiency ## Footnote DPD breaks down Fluorouracil

# Hand-Foot Syndrome (Palmar-Plantar Erythrodysesthesia) Monitoring

S/Sx (eg, painful erythema, skin peeling)

# Hand-Foot Syndrome (Palmar-Plantar Erythrodysesthesia) Management

Limit daily activities to reduce pressure to hands & feet Avoid heat exposure Apply cold compresses for temporary relief Use emollients or topical steroids Modify doses or interrupt therapy for severe cases

# Dihydropyrimidine dehydrogenase (DPD) deficiency Prevention

Pharmacogenomic testing

# Dihydropyrimidine dehydrogenase (DPD) deficiency Treatment of toxicities

Antidote: uridine triacetate for overdose or early-onset toxicity Symptomatic care (specific to the toxicity)

# Pyrimidine analog antimetabolites Drug intxn

Warfarin: Monitor INR (↑) & S/Sx of bleeding

# Folate Antimetabolites MOA

S phase Inhibits dihydrofolate reductase → inhibits tetrahydrofolate activation → inhibiting purine & pyrimidines synthesis

# Folate Antimetabolites Toxicities

Nephrotoxicity (w/ high doses ≥ 500 mg/m2) GI toxicity (eg, diarrhea, mucositis)

# Folate Antimetabolites: Nephrotoxicity Monitoring

Renal function (eg, BUN, SCr) Wt gain Urine pH (target ≥ 7) Methotrexate levels

# Folate Antimetabolites: Nephrotoxicity Prevention

Leucovorin or levoleucovorin "rescue" IV sodium bicarbonate hydration to alkalinize the urine Avoid interaction meds (eg, NSAIDs, salicylates)

# Folate Antimetabolites: Nephrotoxicity Treatment

Antidote: glucarpidase rapidly lowers MTX levels

# Folate Antimetabolites: GI toxicity Monitoring

S/Sx (eg, BM frequency, painful mouth ulcers)

# Folate Antimetabolites: GI toxicity Prevention & Treatment

Diarrhea: antidiarrheals, hydration, electrolyte repletion Mucositis: various Leucovorin or levoleucovorin "rescue"

# Folate Antimetabolites: GI toxicity: Mucositis Monitoring

S/Sx (eg, painful mouth ulcers, difficulty eating) S/Sx of infections (eg, thrush)

# Folate Antimetabolites: GI toxicity: Mucositis Prevention

Good oral hygiene (eg, brushing with a soft toothbrush) Hold ice chips in the mouth Frequent rinsing with bland rinses (eg, sodium bicarbonate solution)

# Folate Antimetabolites: GI toxicity: Mucositis Treatment

Continue good oral hygiene and frequent rinsing Symptomatic care (eg, viscous lidocaine 2%, magic mouthwash) Parenteral nutrition or IV hydration in some cases Thrush treatment (eg, nystatin oral suspension, clotrimazole troches) if indicated

# Tyrosine Kinase Inhibitors Bind to BCR-ABL fusion gene

Imatinib (Gleevec) Dasatinib (Sprycel) Nilotinib (Tasigna)

# Tyrosine Kinase Inhibitors: Bind to BCR-ABL fusion gene Safety Concerns

Fluid retention QT prolongation (nilotinib [Tasigna] ← greatest risk) * Assess QT interval with an ECG * Correct electrolyte abnormalities * Avoid concurrent QT-prolonging drugs & strong CYP3A4 inhibitors Gl upset (eg, abdominal pain) * Take imatinib with food

# Tyrosine Kinase Inhibitors Bind to protein kinase BRAF

Dabrafenib (Tafinlar) Vemurafenib (Zelboraf)

# Tyrosine Kinase Inhibitors: Bind to protein kinase BRAF Safety Concerns

New malignancies QT prolongation

# Tyrosine Kinase Inhibitors Bind to mitogen-activated extracellular kinase (MEK)

Cobimetinib (Cotellic) Trametinib

# Tyrosine Kinase Inhibitors: Bind to MEK Safety Concerns

Retinopathy Rhabdomyolysis

# Tyrosine Kinase Inhibitors Bind to epidermal growth factor receptor (EGFR)

Afatinib (Gilotrif) Erlotinib (Tarceva)

# Tyrosine Kinase Inhibitors: EGFR Safety Concerns

Dermatologic toxicity (eg, acneiform rash) Use general skin care (eg, sunscreen) & PPx measures (eg, antibiotics)