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Pre-reg > Chapter 8- Immune System & Malignant Disease > Flashcards

Chapter 8- Immune System & Malignant Disease Flashcards

1
Q

What’s given with methotrexate (cancer and non cancer treatments) and why

A

Folic acid - non cancer

Folinic acid - cancer

Reduce the possibility of methotrexate toxicity and methotrexate induced myelosuppression

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2
Q

How are chronic inflammatory, autoimmune diseases and organ transplant patients managed on drug regime

A

Antiproliferative drugs (azathioprine, mychophenolate)

Calcineurin inhibitors (ciclosporin or tacrolimus)

Corticosteroids

Sirolimus

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3
Q

What is azathioprine used for

A

Transplant recipients and auto immune conditions

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4
Q

Why should dose of azathioprine be reduced when given with allopurinol

A

Risk of bone marrow suppression

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5
Q

Side effects of azathioprine

A 
Red cell aplasia 
Hypersensitivity reactions (stop immediately)
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6
Q

Monitoring requirements for azathioprine

A

Thiopurine methyltransferace (TPMT) enzyme that metabolises azathioprine

Full blood count for 4 weeks then 3 monthly

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7
Q

What is mychophenolate licensed for

A

The prophylaxis of acute rejection in renal hepatic or cardiac transplantation

(More selective MOA than azathioprine)

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8
Q

Side effects of mycophenolate

A

Bone marrow suppression
Respiratory symptoms
Red cell aplasia
Congenital malformation (so pregnancy prevention)

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9
Q

Warning signs for ciclosporin

A 
Neurotoxicity 
Blood disorders (hyperlipidaemia)
Liver toxicity 
Nephrotoxicity 
Hypertension
Visual disturbances 
Bone marrow 
Gingival hyperplasia (gum overgrowth)
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10
Q

Counselling point for ciclosporin and tacrolimus

A

Avoid UV exposure
Avoid high potassium diet and grapefruit juice
Must not receive immunisation with love vaccines
Stabilise in particular brand

Driving may be impaired (tacrolimus)
Daily dose divided in 2 doses (cislosporin)

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11
Q

What’s the greater disadvantage of tacrolimus over ciclosporin

A

Neurotoxicity is greater
Cardiomyopathy has been reported
Disturbance in glucose metabolism significant

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12
Q

Warning signs for tacrolimus

A

Neurotoxicity (headache and tremors)

Nephrotoxicity

Eye disorder (blurred vision)

Skin disorder (rash)

Blood disorder (BP, hyperglycaemia, hyperkalaemia, hyperuricaemia)
Bone marrow

Cardiovascular disorder (arrhythmia)

Liver toxicity

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13
Q

Monitoring parameters for tacrolimus

A 
BP
ECG
Fasting blood glucose 
Renal function 
Liver function 
Serum electrolytes
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14
Q

What is azathioprine metabolised to?

A

Mercaptopurine

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15
Q

What activity does cytotoxics have?

A

Anti cancer activity and the potential to damage normal tissue
Most are teratogenic

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16
Q

What contributes to determining the cytotoxic drug dose

A

BSA and weight
Dose adjustment is common after considering patients neutrophil count, renal and hepatic function and history of previous adverse effect
Also if the drug is being used alone or in combination

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17
Q

Commonn side effects of cytotoxic drugs

A 
Alopecia 
Thromboembolism 
Tumour lysis syndrome 
Huperuricaemia
Nausea and vomiting 
Bone marrow suppression 
Oral mucositis 
Cardiotoxicity 
Urothelial toxicity 
Myelosupression 
Pregnancy and reproductive function 
Extravasion of IV drugs
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18
Q

Warning signs for methotrexate

A 
GI toxicity 
Liver toxicity 
Blood disorders 
Pulmonary toxicity 
Pregnancy and breastfeeding

Avoid in significant renal impairment

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19
Q

Monitoring parameters for methotrexate

A

Full blood count
Renal function
Liver function

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20
Q

Counselling points for methotrexate

A 
Same day each week (oral)
Folic acid / folinic acid as prescribed
Importance of effective contraception 
Avoid preparations containing NSAIDs/ aspirin 
Methotrexate book issued
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21
Q

What’s a good prevention for oral mucositis from cytotoxics

A

Good oral hygiene

Sucking on ice during chemo

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22
Q

What can be used for cytotoxic associated nausea and vomitting

A

Dexamethasone
Lorazepam
Ondansetron
Metoclopramide

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23
Q

What is cisplatin and Side effects of cisplatin

A

Platinum compound

Nausea and vomiting 
Nephrotoxicity 
Ototoxicity
Peripheral neuropathy 
Myelosuppression
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24
Q

The different routes for methotrexate

A

Mouth
IV
IM
Intrathecally

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25
Q

Adverse effects of vinca alkaloids

A

Neurotoxicity

Myelosuppression

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26
Q

Side effect of tamoxifen

A

Endometrial changes

Risk of thromboembolism

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27
Q

How should vinca alkaloids be administered

A

IV only

IM can be fatal

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28
Q

What’s extravasation?

A

Severe tissue necrosis due to leakage occurring

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29
Q

What drugs can cause oral mucositis

A

Fluorouracil
Methotrexate
Anthracyclines

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30
Q

What worsens hyperuricaemia

A

Chemotherapy and renal failure

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31
Q

Which cytotoxics are highly emetogenic

A

Cisplatin
Dacarbazine
High does Cyclophophsamide

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32
Q

Which cytotoxics are moderately emetogenic

A

Doxorubicin
High dose methotrexate
Low does Cyclophophsamide

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33
Q

Which cytotoxics are mildly emetogenic

A

Fluorouracil
Low dose methotrexate
Radiation therapy
Vinca alkaloids

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34
Q

Which cytotoxics don’t cause bone marrow suppression

A

Vincristine (vinca alkaloids)

Bleomycin

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35
Q

How does cancer effect the risk of VTE

A

Both cancer and chemotherapy increase the risk of VTE

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36
Q

What is multiple sclerosis

A

Chronic immune mediated demyelinating inflammatory condition of the CNS which effects the brain, optic nerves and spinal cord leading to progressive severe disability

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37
Q

How should cytotoxic drugs be handled

A

Trained personnel
Reconstitution carried out in a designated area
Protective clothing should be worn
Eyes should be protected
Pregnant people should avoid exposure
Use local procedures to deal with spillage and safe disposal
Staff exposure to cytotoxic should be monitored

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38
Q

What does tamoxifen treat

A

Breast cancer

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39
Q

Risk of tamoxifen

A 
Embolism 
Endometrial cancer (notice any changes to menstrual cycle)
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40
Q

Risk of doxorubicin

A 
Low RBC (anaemia)
Low WBC (infection)
Low platelet (bleeding risk)
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41
Q

Risk of tamoxifen

A 
Embolism 
Endometrial cancer (notice any changes to menstrual cycle)
42
Q

How does azathioprine and mercaptopurine work

A

Azathioprine is metabolised to mercaptopurine

Mercaptopurine inhibits purine metabolism therefore dna and rna and protein synthesis

43
Q

How does allopurinol and azathioprine and mercaptopurine interact

A

Allopurinol is a Xanthines oxidase inhibitor so inhibits metabolism of purine

Increasing risk of bone marrow suppression

44
Q

How long should males and females use contraception for after mycophenalate

A

Men: use condoms until 90 days after discontinuing

Women: two methods of effective contraception until 6 weeks after discontinuing

45
Q

Which cytotoxic affect male fertility

A

Alkylating drugs and procarbazine

Counsel patients on sperm storage

46
Q

What clinical features can occur from tumour lysis syndrome

A 
Hyperkalaemia 
Hyper urea 
Hypocalceamia 
Renal failure 
Arrhythmia
47
Q

Which group of patients are at risk of tumour lysis syndrome

A

Renal impairment
Dehydration
Hyperuricaemia

48
Q

Treatment for urothelial toxicity

A

MESNA

49
Q

Which cytotoxics lead to extravasation of IV drugs

A

Vinca alkaloids

Anthracyclines

50
Q

Side effects of cytotoxics

A 
Tumour lysis syndrome 
Thromboembolism 
Urothelial toxicity 
Pregnancy and reproductive function 
Hyperuricaemia 
Nausea and vomiting 
Alopecia 
Extravasation of IV drugs 
Bone marrow suppression
51
Q

Name the cytotoxic drug classes and examples

A

Cytotoxic antibiotics (Anthracyclines ‘rubicin’ and Antineoplasric antibiotics ‘bleomycin’

Vinca alkaloids (vincristine)

Antimetabolites (methotrexate)

Alkylating drugs (cyclophosphamide)

Aromatase inhibitors (anastrazole)

Taxanes (paclitaxel)

52
Q

Side effects of anthracyclines

A

Cardio toxicity
Red urine
Hand and foot syndrome

(Doxorubicin excreted in bile so reduce dose if high bilirubin)

53
Q

Treatment fo anthracyclines induced side effects

A

Dexrazoxane

54
Q

Side effects of antineoplastic antibiotics

A

Pulmonary fibrosis
Respiratory failure
Hypersensitivity
Dermatology toxicity

55
Q

Route of administration for vinca alkaloids

A

Intravenous only

56
Q

Side effect of vinca alkaloids

A

CNS toxicity

57
Q

Antimetabolites side effects

A

Oral mucositis

Myelosuppression

58
Q

How can you speed up the recovery of methotrexate use for chemo

A

Folinic acid

59
Q

Which cytotoxics causes urothelial toxicity

A

Cyclophosphamide

60
Q

Which cytotoxics are not for premenopausal women and why

A

Aromatase inhibitors

They are anti-oestrogen

61
Q

Side effect of taxanes

A

Cardiac disease
Pneumonitis
Sepsis

62
Q

What can you give before chemo for nausea and vomiting

A

Lorazepam

63
Q

What can you give for acute symptoms of nausea and vomiting associated with chemo

A

Low risk: dexamethasone or lorazepam

High risk: serotonin antagonist, aprepitent + dexamethasone

64
Q

What can you give for delayed symptoms of nausea and vomiting associated with chemo

A

Moderately emotogenic drugs:
Dexamethasone and serotonin antagonist

Highly emotogenic drugs:
Dexamethasone + aprepitant

65
Q

Treatment for hyperuricaemia associated with chemotherapy

A

Allopurinol (24hrs before treating tumour)

Of febuxostat (2 days before)

Rasburicase (hyperuricaemia associated with blood cancer)

66
Q

What is extravasation of IV drugs

What can chemo drugs cause

A

Leakage of drugs into surrounding tissue

Extravasation of cytotoxics can lead to permanent tissue damage

67
Q

Chemotherapy can cause Neutropenic sepsis, a MEDICAL EMERGENCY. This is essentially neutropenia. What are the symptoms?

A

General Malaise/ high temp above 37.5 (due to infection)

Shivering/ flu-like symptoms

Uncontrolled gum/ nose bleeds (due to low platelets)

Bruising

Mouth ulcers (worse than usual)

Diarrhoea/ uncontrolled vomiting (dont forget- chemo can cause some vomiting itself)

Advise patient to go to A&E asap and not to take paracetamol

68
Q

Which Chemo drugs can only be given by IV administration only?

A

VINCA ALKALOIDS

e.g. Vinblastine, Vincristine (all the Vin’s)

69
Q

Which two immunosuppressant drugs used in chemo have a lot of interactions, plus must always maintain the same brand?

A

Ciclosporin

Tacrolimus

70
Q

Which chemo drugs have a lower emetogenic (vomitting) potential?

A

Methotrexate

Vinca alkaloids- vinblastine, vincristine

Highly emetogenic: Cisplatin, dacarbazine

71
Q

How much will a patient recieving treatment for unpleasant side effects they experienced from their last dose of chemotherapy, have to pay for their prescription of Folinic acid (used for methotrexate side effects)?

A

Nothing- free

Those on cancer meds and on meds for effects of cancer are medically exempt

72
Q

Tamoxifen is usually used for breast cancer at a dose of 20mg daily. It can increase the risk of another cancer: ______ cancer. It can also result in thromboembolism and patients are required to report symptoms like?

A

Endometrial cancer

Symptoms such as SOB, pain in one leg

73
Q

Which class of chemotherapy drug is Cardio toxic and associated with cardiomyopathy?

A

Anthracyclines eg

Doxorubicin

Epirubicin

Daunorubicin

74
Q

What class of anti cancer drugs are useful for lung and breast cancers?

A

Vinca- alkaloids (vincristine, vinblastine)

Also for Leukaemias and Lymphomas

75
Q

What drug is used as a protectorant from cytotoxic induced urothelial toxcitiy such as heamorrhagic cystitis/ blood in urine?

A

MENSA

76
Q

What would a high temperature following a dose of Chemo indicate?

A

Febrile Neutropenia

Remember neutropenia warning signs = fever- this is all it is

77
Q

Which 2 anticancer drugs DO NOT cause bone marrow suppression?

A

Bleomycin (an anthracycline cytotoxic antibiotic)

Vincristine

78
Q

When does bone marrow suppression, caused by most chemo drugs bar vincristine and bleomycin, usually occur?

A

7 -10 days after administration

79
Q

What pre-treatment screening is needed with azathioprine?

A

TPMT levels TPMT metabolises the drug, so if reduced levels, there is an increased risk of myelosuppression

80
Q

When monitoring tacrolimus, should peak or trough levels be taken?

A

Trough Especially when there is diarrhoea, levels need to be closely monitored

81
Q

What is the MHRA advice surrounding the use of bevacizumab?

A

Risk of osteonecrosis of the jaw

82
Q

What is the MHRA advice surrounding the use of EGFR inhibitors e.g. cetuximab?

A

Keratitis and ulcerative keratitisIn rare cases, this has resulted in corneal perforation and blindness

83
Q

What is the MHRA advice surrounding the use of nivolumab?

A

Risk of organ transplant rejection

84
Q

What are the features of tumour lysis syndrome?

A

Hyperkalaemia, hyperuricaemia, hyperphosphataemia withhypocalcaemia; renal damage and arrhythmias

85
Q

How is acute nausea and vomiting symptoms managed in low risk chemotherapy patients?

A

Dexamethasone or lorazepam

86
Q

How is acute nausea and vomiting symptoms managed in high risk chemotherapy patients?

A

5HT3 antagonist e.g. ondansetron + dexamethasone + aprepritant

87
Q

What colour does doxorubicin turn your urine?

A

red

88
Q

What monitoring needs to be done before starting doxorubicin?

A

ECG due to the cardiotoxicity

Monitor during treatment too

89
Q

How is it recommended that methotrexate tablets are dispensed?

A

Single strength tablets only to avoid confusion, usually 2.5mg tablets

90
Q

What is the MHRA warning regarding the use of imatinib?

A

Can cause reactivation of Hepatitis B

91
Q

What is the first sign of methotrexate GI toxicity?

A

Stomatitis Inflammation of mouth and lips

92
Q

What OTC medicines should a patient on methotrexate not have?

A

NSAIDs - aspirin, ibuprofen

Patients should be counselled on the use of NSAIDs

93
Q

True or false: Penicillins increase toxicity risk of methotrexate

A

TRUE

94
Q

What does the MHRA suggest for excluding pregnancy when starting MMF?

A

The MHRA advises to exclude pregnancy in females of child-bearing potential before treatment—2 pregnancy tests 8–10 days apart are recommended.Pregnancy prevention programme

95
Q

What biomarker can you measure to see if you need to reduce the dose of doxorubicin?

A

Doxorubicin is largely excreted in the bile and an elevated bilirubin concentration is an indication for reducing the dose.

96
Q

What bags should vincristine and vinblastine go in for adults and teenagers to prevent it from being administered intrathecally?

A

50mL mini bagShould also have a sticker on to say “For IV use only”

97
Q

Can chemotherapy prescriptions be on repeat?

A

No unless indicated by a specialist

Dose is dependent each time on a lot of factors e.g. blood count

98
Q

What is the bowel cancer screening programme e.g. age, what does the patient need to do, how often, what gender?

A

In England, people between the ages of 60 and 74 years take part. Both male and female
Every 2 years
Send off a stool sample You need to be registered with a GP to receive screening invitations

99
Q

What is the breast cancer screening programme e.g. age, how often, what does the patient need to do,?

A

50-70 years
In some areas this extends from 47 to 73 years Every 3 years Mammogram You need to be registered with a GP to receive screening invitations

100
Q

What is the cervical cancer screening programme e.g. age, how often?

A

25-49 years every 3 years49-64 years every 5 years Need to be registered with GP

101
Q

What would you give for a fever with neutropenia following bone marrow suppression due to cytotoxic drugs

A

Broad spec antibiotic
Filgrastrim- stimulate more wbc
Avoid paracetamol as it delays starting antibiotic

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