Block 3 More Flashcards by Markus M

Ovarian cancer and when it’s discovered, whats the issue?

Once it’s found, its usually stage 3/4 so survival rate is kinda doodoo

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RF for ovarian cancer?

Age ≥70

Menopause

Late pregnancy ≥35yo

2+ more 1st degree relatives w/ this cancer

Breast cancer FH

Estrogen w/o progesterone for ≥10yrs

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Poor prognostic factors for ovarian cancer?

Clinical stage (most important, usually stage III)

Grade of tumor

BRCA1/2 (higher chance of cancer, but survival is higher, hmmm)

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Prevention + screening for ovarian cancer?

Prevent via:

oral contraceptives ≥5yrs
Surgery RRSO
Have given birth
Breastfeeding >1yr

Screening: nothing really, but high risk can do surgery RRSO between age 35-40 after child is born

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Surgery goals + ovarian cancer?

Microscopic = no residual disease

Optimal <1cm

Suboptimal >1cm

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Surgery for ovarian cancer, fertility and no fertility requirements?

Fertility wanted = 1A or 1C, one ovary is removed, 1B = both ovaries removed

No fertility needed = I - IV; total removal of uterus + ovaries or just both ovaries alone

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Generic chemo for ovarian cancer includes..?

Taxane + Platinum agent

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Carboplatin AE?

Hypersensitivity, N/V

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Bevacizumab dosing and surgery considerations and AE?

1st dose = 90min
2nd = 60
3rd = 30

Hold for 6 weeks from debulking post op

AE = bleed, decreased wound healing, GI issues

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Intraperitoneal chemo requirements for ovarian cancer?

Stage 3 (<1cm)

Overall, pretty good standing

≤65yrs old

No prior surgery

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Intraperitoneal toxicity management?

Warm IP to body temp

Hydration

Anti-emetics

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Rucaparib
Olaparib
Niraparib

AE?

Rucaparib = cholesterol, liver

Olaparib = pneumonitis

Niraparib = HTN, palpitations

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RF for cervical cancer?

HPV 16 + 18 (most important factor*)

Early sexual h/o (<18)

Multiple partners

Oral contraceptives >5yrs

Smoking

Immunosuppression

≥3 full term pregnancies

Low socioeconomic status

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What is the gardasil vaccine?

HPV vaccine for ages 9-45 for both men and women

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Gardasil scheduling?

Age 9-14; 2 dose series at months 0 and 6-12

15-45; 3 dose series at months 0,2,6

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What makes up most of the cervical cancer cases (what cell type)?

Squamous cell carcinoma

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Whats given in cervical cancer w/ radiation?

Radiation + cisplatin or carbo or cisplatin + 5-FU

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Chemo regimen for advanced/recurrent cervical cancer

Cis/carboplatin + paclitaxel + bevacizumab

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What drug/classes are used for induction immunosuppression?

ATG (rabbit + equine)

Basiliximab

Methylprednisolone

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ATG class MOA?

Polyclonal AB that deplete T cells

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ATG class AE?

Cytokine release syndrome; fever, chills, rigors, pulmonary edema, hypotension

^pre-treat with APAP, benadryl, steroids. If rigors keeps existing, use meperidine/cyclobenzaprine

Cytopenia

Infection

PTLD

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Basiliximab MOA?

Chimeric monoclonal AB that targets CD-25/IL-2. It does NOT deplete T cells, but rather makes them inactive for 4-6 wks

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Basiliximab AE?

Virtually none, no premedication required

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Who needs ATG drug?

Young, black, blood group incompatibility issues, DGF/DSA or PRA>20%, cold ischemia time >24hrs, and those who need to avoid steroids

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What drugs are used for maintenance immunosuppression?

Calcineurin inhibitors (cyclosporine, tacrolimus) Anti Proliferatives (Aza, MMF, MPS, mTORi) Steroids Co-stimulation inhibitor (belatacept)

How is cyclosporine monitored via peak/trough?

Use 2 hr peak and 12 hr trough; C2 is better for cyclosporine due to differences in formulations

Cyclosporine AE?

Gingival hyperplasia, HTN, hyperlipidemia, kidney damage, hirsutism

What kind of substrate is cyclosporine?

P-gp + CYP3A4 Inducers ~ carbamazepine, rifampin, phenobarbital, phenytoin, st. johns wart = so less cyclosporine levels

What should be avoided when taking cyclosporine?

NSAIDs, aminoglycosides, amphoteracin

Tacrolimus vs Cyclosporine monitoring peak/trough differences?

Tacrolimus correlates well with the 12hr trough

Tacrolimus AE?

Tremors, diabetes, alopecia

Azathioprine MOA?

Prodrug converted to 6-MP that is a purine (A/G) analog that inhibits both T + B cells

Azathioprine AE?

Liver issues, consider lowering dose/dc if they have infection

Azathioprine DDI?

Allopurinol

Mycophenolate MOA?

Inhibits IMPHD and depletes guanosine stores and also blocks T + B cells More effective vs Azathioprine

Conversion of MMF to MPS?

1000mg MMF = 720mg MPS

MMF/MPS AE?

N/V/D; consider lowering dose/dc if they have infection MPS has better GI effects

MMF/MPI DDI?

PPI only affect MMF

Sirolimus MOA?

mTOR inhibitor Prevents G1 to S phase of cell cycle Blocks IL-2 mediated T cell proliferation

How is sirolimus monitored via peak/trough?

Only checks 24hr trough 12hr trough for everolimus though

Sirolimus AE?

Hypertriglyceridemia, thrombosis, proteinuria, delayed wound healing BBW: give med after a month with liver transplant and 3 months for lung transplant due to artery thrombosis

Belatacept MOA?

Co-stimulates CD28 to CD80/86

How to you treat acute (cellular) rejection?

Mild/Moderate = methylprednisolone 500mg IV 3-5days + augment therapy Moderate/Severe = methylprednisolone 500mg IV 3-5days + augment therapy + anti-thymocyte agent

What are the sources of stem cells?

Peripheral blood stem cells thru leukapheresis Umbilical cords Bone marrow from iliac crest

G-CSF drugs? MOA?

Filgrastim Makes more neutrophils

G-CSF AE? PK?

Bone pain Onset = 1-2 days

GM-CSF drugs? MOA?

Sargramostim Makes more neutrophils, eosinophils, monocytes, macrophages

GM-CSF AE? PK?

Capillary leak syndrome, infusion related issues, SVTs, plus a lot of AE CI = yeast allergy Onset = 7-14 days

Plerixafor AE? PK? Monitoring?

Onset = 6-9hrs Will cause fetal harm (use back up method for 1wk after) Must be given w/ or after filgrastim

Donors of peripheral blood stem cell, what do they have to do?

~5 days prior to donating, they must be on daily mobilizing agents

Autologous vs allogeneic Which one is donor ≠ host?

Allogenic Autologous donor is host

Autologous vs allogeneic Which one REQUIRES MAC?

Autologous requires just that one Allogeneic can use MAC or RIS

Autologous vs allogeneic Which one is cure the final objective?

Allogeneic

Autologous vs allogeneic Which one requires immunosuppression?

Allogeneic

Autologous vs allogeneic Which one has a lower risk of graft failure?

Autologous

Purpose of Ursidiol?

Prevent SOS (sinusoidal obstructive syndrome)

Acute GVHD clinical presentation? Chronic

Skin, Liver, GI issue (usually <100 days) Chronic hits all organs

How is chronic GVHD categorized?

Mild = 1-2 organs affected insignificantly (except lungs) Moderate = 1 significant organ affected or 3+ organs not significantly affect or mild lung impairment Severe = moderate lung impairment or 1 major organ disability

What are the high risk patients for infection?

Allogeneic Alemtuzumab users Acute leukemia High dose steroids (>20mg prednisone) Anticipated neutropenia >10days

Physiologic response of infection in NON neutropenic pt vs neutropenic pt?

NON = chills, fever, increased WBC, microbiology results Neutropenic = just fever

Definition of fever?

Oral temp ≥38.3 C or 101 F ≥38 C or 100.4 F for ≥1hr

Bugs found in neutropenia?

G+ = S. aureus G- = Pseudo + Entero

Low vs High MASCC and whats included in the high category?

≥21 = low <21 = high; duration 7-10 days, allogeneic, alemtuzumab

What do give during neutropenic prophylaxis? Bacterial? Fungal? HSV/VSV?

Bacterial = FQ Fungal = Triazole or echinocandin HSV/VSV = acyclovir or valacyclovir All duration is during neutropenia

Outpatient + oral TREATMENT of neutropenic fever

Cipro AND Augmentin | Levo

Inpatient + TREATMENT of neutropenic fever? Complications?

Cefepime is DOC Can do ceftazidime, carbapenem, or zosyn Infected line? Add vanco Pneumonia during flu season? Add oseltamivir