Pharmacology/Conditioning Regimens

Question 1

Abatacept

Answer 1

biological agent, interferes with T-cell activation

Question 2

Eculizumab

Answer 2

immunosuppressive drug, can treat TMA

Question 3

Rituximab

Answer 3

Targets CD20+ B cell malignancies; due to infusion reactions (common s/e), use premeds then start at slow rate and titrate up; also screen for HBV

Question 4

Autologous Car T cell therapy

Answer 4

Genetically modifying T-cells to fight cancerous cells; alter genes inside T-cells by adding chimeric antigen receptor (CAR) that will help T-cells attach to specific cancer cell antigen (ex: CD19 antigen in certain lymphomas and leukemias)

Question 5

KYMRIAH

Answer 5

CAR-T cell medication used to treat B-cell leukemia, using bodies own T-cells, modifying them, and then re-implanting them to fight cancerous cells

Question 6

Tacrolimus

Answer 6

Immunosuppressive drug/calcineurin inhibitor that works against helper T-cells, preventing production of IL-2

Question 7

Campath

Answer 7

Also known as alemtuzumab - commonly causes hypersensitivity reaction
May cause rigors - so have Demerol on hand

Question 8

Ursodiol

Answer 8

VOD ppx

Question 9

Cyclophosphamide common s/e

Answer 9

1. n/v
2. Hemorrhagic cystitis due to acrolein as byproduct of cytoxan
3. SIADH - b/c Cytoxan can be toxic to renal collecting tubulues and anti-diuretic hormone activity

Question 10

Cytoxan management (2, think ppx)

Answer 10

1. MESNA
2. Hyper hydration (using fluid containing at least 0.45% NaCl. Achieve urine specific gravity ≤ 1.010 prior to start of cyclophosphamide)

Question 11

Cyclophosphamide adverse effects (4)

Answer 11

1. n/v
2. Hemorrhagic cystitis due to acrolein as byproduct of cytoxan
3. SIADH - b/c Cytoxan can be toxic to renal collecting tubulues and anti-diuretic hormone activity
4. cardiotoxicity

Question 12

Busulfan and pharmacokinetics

Answer 12

type of chemotherapy; pharmacokinetics are very important, always get busulfan levels to monitor for steady stead
If too high - risk of VOD
If too low - won’t kill cancer cells // or risk for engraftment failure

Question 13

Carboplatin, cisplatin (platins) monitoring (3)

Answer 13

1. Ototoxic, need baseline audiogram
2. Highly emetogenic, but can be delayed n/v
3. Kidneys - very nephrotoxic

Question 14

Etoposide monitoring (2)

Answer 14

1. hypersensitivy rxns b/c it contains preservative

2. hypotension - monitor BPs (if hypotensive, stop infusion, give bolus, then restart at 1/2 rate)

Question 15

Targeted AUC range for non-myeloablative busulfan dosing

Answer 15

600-750

Question 16

Busulfan infusion

Answer 16

Always starts with saline, not Bu, and ends with NS flush so that drug level reflects entire dose infused
*Stop clock should be involved for Bu kinetcs

Question 17

Common toxicities of Busulfan (7)

Answer 17

1. N/v - give IVF and anti-emetics
2. Mucositis
3. Seizures (ppx with anticonvulsant, usually Ativan)
4. Myelosuppressive (decreased BMT activity - fewer WBC, RBC and platelets)
5. Skin changes: bronzing and darkening of skin - temporary
6. Hepatotoxicity
7. Intersitial Pneumonia

Question 18

Busulfan seizure prophylaxis

Answer 18

Anti-convulsant, usually Ativan, give during Bu administration and 48h after; if it is a sickle cell patient, use Keppra (30mg/kg)

Question 19

Busulfan and hepatotoxicity (4: risk factors, management, ppx, treatment)

Answer 19

1. Risk factors: Fe overload, abnormal LFTs, previous chemo, previous abdominal radiotherapy
2. Monitor: weight, LFTs, I&Os, abd circumference, liver size
3. Prophylaxis: Ursodiol/Actigall
4. Treatment: defibrotide to treat VOD

Question 20

Common toxicities of Busulfan (7)

Answer 20

1. N/v - give IVF and anti-emetics
2. Mucositis
3. Seizures (ppx with anticonvulsant, usually Ativan)
4. Myelosuppressive (decreased BMT activity - fewer WBC, RBC and platelets)
5. Skin changes: bronzing and darkening of skin - temporary
6. Hepatotoxicity
7. Intersitial Pneumonia

Question 21

Melphalan

Answer 21

Chemotherapy drug that crosses BBB so good for CNS tumors, also good for multiple myeloma
Has decreased risk of VOD because it is metabolized in blood stream and not liver

Question 22

Common toxicities of Melphalan (6)

Answer 22

1. N/v
2. Mucositosis - common
3. Myelosuppression
4. Hypersensitivity reactions - monitor during infusions*
5. Hepatotoxicity
6. Pulmonary fibrosis (rare)

Question 23

Common toxicities of Busulfan (7)

Answer 23

1. N/v - give IVF and anti-emetics
2. Mucositis
3. Seizures (ppx with anticonvulsant, usually Ativan)
4. Myelosuppressive (decreased BMT activity - fewer WBC, RBC and platelets)
5. Skin changes: bronzing and darkening of skin - temporary
6. Hepatotoxicity – VOD RISK***
7. Intersitial Pneumonia

Question 24

Melphalan stability

Answer 24

Stable in 0.9% NaCl for 90 minutes at room temperature, meaning 90 min from pharmacy dispensing - ensure it will not expire during infusion

Question 25

Thiotepa

Answer 25

Type of chemotherapy that crosses BBB so good for brain tumors

Question 26

Common toxicities of Thiotepa (4)

Answer 26

1. N/v 2. Mucositis - may be severe 3. Myelosuppression 4. Skin changes - b/c it is excreted in skin and can cause burns, nursing does bed baths every 8h at start of infusion through 24h after - hyperpigmentation may occur for several weeks but will fade

Question 27

Common toxicities of Carboplatin (7)

Answer 27

1. Nephrotoxic - watch creatinine level closely and give fluids (make sure 12h urine creatinine is good, and dose using Calvert Formula, monitor serum electrolytes) 2. N/v 3. Hepatotoxicity - monitor LFTs 4. Peripheral neuropathy - damage to nerves outside brain and spinal cord, usually resulting in weakness and numbness, common in hands & feet 5. Allergic rxns (skin rash, urticaria, pruritis, bronchospasm, etc) 6. Ototoxicity - need to do baseline audiogram before and after

Question 28

Common toxicities of Carboplatin (6)

Answer 28

1. Nephrotoxic - watch creatinine level closely and give fluids (make sure 12h urine creatinine is good, and dose using Calvert Formula, monitor serum electrolytes) 2. N/v 3. Hepatotoxicity - monitor LFTs 4. Peripheral neuropathy - damage to nerves outside brain and spinal cord, usually resulting in weakness and numbness, common in hands & feet 5. Allergic rxns (skin rash, urticaria, pruritis, bronchospasm, etc) 6. Ototoxicity - need to do baseline audiogram before and after

Question 29

Common toxicities of Etoposide (7)

Answer 29

1. Hypotension - if occurs, then stop infusion, once it resolves restart at 1/2 rate; may also give bolus fluids 2. N/v 3. Myelosuppresion 4. Mucositis 5. Hepatotoxicity 6. Peripheral neuropathy 7. Hypersensitivity rxn

Question 30

How to prevent etoposide hypersensitivity rxn

Answer 30

NEVER INFUSE VOLUME IN LESS THAN 1 HOUR AND NEVER DILUTE INCORRECTLY Monitor V/S

Question 31

Biological agents and four types

Answer 31

Agents that can target specific things to gain anti-cancer effects, may be administered before or after transplant 1. Rituximab - targets CD20+ B cell malignancies 2. Campath - targets CD52 3. Atgam - targets T cells 4. Thymboglobulin (ATG) - targets T cells

Question 32

Biological agents and four types

Answer 32

Agents that can target specific things to gain anti-cancer effects, may be administered before or after transplant 1. Rituximab - targets CD20+ B cell malignancies 2. Campath - targets CD52 3. Atgam (ATG) - targets T cells 4. Thymboglobulin - targets T cells

Question 33

ATG

Answer 33

1. Targets T cells 2. Use as an inducing agent to produce lymphopenia, causing longterm suppression of T cells and immune dysfunction 3. Can commonly cause hypersensitivity reactions, also need to have Demerol as emergency med

Question 34

Cyclosporine

Answer 34

immunosuppressive drug that works against helper T-cells, preventing production of IL-2 via calcineurin inhibition Used for induction & maintenance immunosuppression IV much more potent than PO (increased risk for nephro and neurotoxicity) Monitor nephrotoxicity closely - watch Cr, K, Mg

Question 35

Side effect profile of immunsuppressive drugs (such as Tacro, Cyclo) (5)

Answer 35

1. Reversible alopecia 2. Nephrotoxic - monitor Cr closely 3. Glucose intolerance 4. N/V/D 5. Infection

Question 36

Florinef

Answer 36

(fludrocortisone) used to regulate high K levels; decreases potassium levels in the blood

Question 37

MMF/Cellcept

Answer 37

Immunosuppressive drug that slows proliferative pathway of B&T cells; unique b/c it lacks cardio and nephrotoxicities

Question 38

Monoclonal antibodies and 3 types

Answer 38

Target against specific immunoreactive cells by recognizing cell-surface antigens 1. Alemtuzemab 2. Daclizumab 3. Infliximab

Question 39

Bactrim ppx - when to use, and dose

Answer 39

Use it daily from first day of conditioning to day -2, then restart once ANC >500 x 2 consecutive days 5mg/kg max: 160mg, three times weekly

Question 40

HSV ppx, Acyclovir - when to use

Answer 40

Begin on first day of conditioning through ANC >500 x 3 days post-nadir Do not need to give if both donor & recipient are (-)

Question 41

Fungal ppx

Answer 41

Micafungin IV starting on day 0 | Switch to fluconazole when ready for PO/discharge

Question 42

cytarabine common side effect

Answer 42

chemotherapy agent that may cause conjunctivitis - give steroid drops

Question 43

Hydroxyurea

Answer 43

Type of chemo agent used to treat leukemias

Question 44

Allopurinol

Answer 44

Used to reduce uric acid (waste product found in blood when body breaks down purines - can increase in blood when cancer cells die) in cancer patients