CHEMOSH1

Question 1

Cell Cycle and what drugs work where

Answer 1

M phase : cell mitosis ( cell division ) - [ Vinca Alkaloids ; Taxanes )
G1/G0 phase: cell makes enzymes for dna synthesis [ ( Alkylating agents and Anti Tumor ABX - these are non cell cycle specific and realize they work on multiple phases )

S Phase: cell replication of DNA ( Antimetabolites ) ( MTX , 5FU, Capcetabine ( xeloda ), 6 mercaptopurine )

G2: RNA and other proteins are synthesized to prepare for cell division during M phase ( plant alkaloids- Etoposide, Teniposide, Irinotecan )

Question 2

Cell cycle specific and cell cycle non specific

Answer 2

Cell cycle specific:
• eg ) Antimetabolites ( MTX ) ; Vinca Plant Alkaloids

Cell cycle non specific :
• alkylating agents , cytotoxic ABX

Question 3

problems associated with chemo

Answer 3

N/V ( most NV is cisplantin ( platinol )

Bone Marrow : neutropenia , thrombocytopenia, Anemia

Tumor lysis syndrome

Chemo induced peripheral neuropathy

Question 4

Treat N/V

Answer 4

1 ) 5- HT3 serotonin R blockers
• Dolasetron ( Anzemet ), Granisetron ( kytril ), Ondansetron ( zofran ), palonsetron ( aloxi )

2) Corticosteroids: dexamethasone

3) Neurokinin ( NK ) - 1 Receptor antagonists
• aprepitant ( Emend ) ( PO ) / Fosaprepitant ( IV ), Rolapitant ( Varubi ) ( PO )

4) Cannabinoids: dronabinol ( Marinol ), Nabilone ( Cesamet )

5) Dopaminergic antagonists: metoclopramide ( reglan ) [[[ dont give to Parkinsons pts. Dont want to decrease dopamine in parkisons patients )

6) antihistamines, Benzodiazepines - antihistamines can be used but really not used bc not strong enough / benzodiazepines is off label use. Can be used if you see question.
7) pts on CISPLATIN or other highly emetogenic can add olanzapine ( off label)

Question 5

5HT3 inhibitors

All of these you worry about qt prolongation

Answer 5

Dolasetron- anzemet
IV and PO. Due to qtc prolongation IV is contraindicated for CINV

Granistron : IV/ SQ/ PO / tabs / transdermal
• IV ( kytril ) : 1 mg 30 mins prior to tx
• PO ( Granisol ) : 1 hour prior
• ER SQ ( Sustol ) : Q7 days 30 mins before chemo
• Transdermal ( Sancuso ) : 24 - 48 hours before chemo for up to 7 days. Avoid sun

Ondansetron :
Zofran: IV/ IM. / PO ( odt )
Zuplenz ( thin strip odt like )

Palonsetron - ALoxi ( Use ALOXI if worrying about QT prolongation )
IV only

COMBO: neutapitant + palonsetron ( alkynzeo )

Question 6

CORTICOSTEROIDS

Answer 6

Used alone or w/5HT3 antagonists

Dexamethasone ( decadron )

Methylprednisolone ( medrol )

Question 7

NK-1 receptor blocker
Add on

Neurokinin 1

Answer 7

• aprepitatn ( emend ) PO -sub of 3a4 ( also inhibitor of 3 a4 )

• Fosaprepitant ( Emend IV ) - sub of 3A4 ( also inhibitor of 3a4)
- 1) 2) need to give day 2 and 3 bc not long half life

• Rolapitant ( Varubi PO ) ( not a 3 a4 inhibitor bud does effect 2d6 inhibitory ) - what med goes through 2d6 to get activated? Tamoxifen
• Rolapitant: long half life ( give day1 only )

NK1 R Antagonists work by blocking substance P, which activates a pathway in the brain that causes N/V

Question 8

Cannabinoids

Answer 8

Dronabinol ( marinol / syndros ) ( schedule 3 )
Marinol refrigerated have to give 1- 3 hours before then q2-4 hrs
Syndros

Nabilone ( cesamet ) c2 used BID

Question 9

Dopamine antagonists

Answer 9

Metoclopramide ( reglan ) : blocks dopamine in the brain vomiting center
- never give to Parkinson’s patients
SE: diarrhea, drowsiness, extrapyramidal side effects ( spasms )
- if they get extrapyramidal side effects then give Benadryl bc it’s anticholinergic

Prochlorperazine
- PO tabs
- rectal suppository ( Compro )

Question 10

Antihistamines

Answer 10

Commonly used to control N/V but not very effective for cancer induced N/V

Diphenhydramine

Hydroxyzine : vistaril ; atarax

S/E: mild relaxation, drowsiness, dry mouth, constipation ( anticholinergic)

Question 11

Benzodiazepines
NOT FDA approved but off label

Answer 11

Lorazepam ( Ativan )

Usually add on. Not effective at all alone for chemo induced N/V

Question 12

Chemo induced anemia

Answer 12

No FDA approval for patients that have a cure for cancer. If no cure you may use can cause thromboembolic effects and tumor growth

Erythropoietin ( epogen, Procrit ) ( also used in ESRD ) ( zidovudine induced anemia ) ( and patients without a cure )
Discard vial after 21 days. Given once weekly

Darbepoetin Alfa ( aranesp ) : benefit not given as often. Once every 3 weeks.

Chemo doesn’t cause anemia right away. RBC live up to 120 days.

Both do not shake protect from light. Refrigerate. Any crystals, then discard.
Cannot use if BP high. REMS drug: increases risk of CV, thormboembolic events and tumor progression.

keep Hgb between 10-11 g/dl ( IF treating zidovudine induced anemia then up to 12g/dL )

MONITOR: BP, HgB 10 -11 ( zidovudine 12) , serum ferritin ( without iron bone marrow cant make RBC start iron if serum ferritin < 100 mcg/ml ) , folic acid level
Correct iron b12 and folate prior to tx

Question 13

Chemo induced Thrombocytopenia

Answer 13

Neumega ( oprelvekin ) it’s DC’d
Neumega : megaplatelets
It’s DC’d but recognized it’s used for thromobocytopenia

Question 14

Neutropenia

Answer 14

Neutrophils live 6- 8 hours

Question 15

Chemo induced Leukopenia ( ↓WBC )

Answer 15

Filrastim ( Granix, Neupogen, zarxio( biosimilar form ) )
5mcgk/kg /day
24 hours RT

Pegfilgrastim ( * Neulesta ) : pegalated form. Benefit you dont give as often.
6mg 1x each chemo cycycle
48 Hours RT

SE for BOTH : Bone pain.
Can be really bad for certain patients.

Question 16

Tumor lysis Syndrome:

Answer 16

Lysis of tumor cells results in rapid release of K+, purine nucleic acids, PO4, which leads to HYPERKALEMIA, HYPERURICEMIA, and HYPERPHOSPHATEMIA with secondary HYPOCALCEMIA

These metabolic abnormalities can subsequently lead to acute renal failure ( ARF ) and multiple organ failure —-> death

Can also cause cardiac arrhythmia ( hyperkalemia )
Tx: get k+ into cell. Give sodium bicarbonate, insulin and glucose, b2 agonists . Then kayexolate to actually get rid of k+ ( kayexolate takes time, thats why you first try to k into the cell )

HYPERPHOSPHATEMIA ( PhosLo : calcium acetate , other non ca agents Sevelamer , renagel )

HYPERURICEMIA: allopurinol ( watch out for DDI : 6MP ) and hydration
Azathiopurine : becomes 6MP

Question 17

HYPERPHOSPHATEMIA

Answer 17

PhosLo: calcium acetate. ( SE: constipation, hypercalcemia )

• Sevelamer ( renagel; revela ) w/food

Aluminum hydroxide : AleenaGel ; amphogel ( never give amphogel to patient who has CKD; aluminum toxicity )

Question 18

Hyperkalemia

Answer 18

( need to protect heart )
1) give IV calcium :
Calcium chloride has a lot more elemental calcium than calcium gluconate. However calcium gluconate easier to give and doesn’t irritate when giving IV.
If you need to give calcium chloride use a central line.

2) get k into cell. Sodium bicarbonate : shifts k intracellularly. Insulin and dextrose : IV regular insulin induces intracellu lar flux of k+.
Kayexalate: gets rid of extracellular k+ . Sodium polystyrene sulfonate : exchanges Na+ for K+ and binds it in the gut to ↓total body K+. Onset after
Beta2 agonists: drives K into the cells.

Veltassa: doesn’t increase sodium levels and binds to potassium.
Both cause constipation

Question 19

Calcium chloride has a lot more elemental calcium than calcium gluconate

Answer 19

T

CaCl: 1g = 270 mg of elemental calcium

Ca Gluconate: 1 g = 90 mg of elemental calcium

Question 20

CIPN
Chemo induced pheripheral neuropathy

Answer 20

• Platinum drugs: cisplatin , carboplatin, oxaliplatin
• Taxanes: paclitaxel ( Taxol ), docetaxel ( taxotere ), and cabazitaxel ( Jevtana )
• Epothilones: ixabepilone ( ixempra )

•plant alkaloids : vinblastine, vincristine, vinorelbine, and etoposide ( VP -16)
• thalidomide ( Thalomid ), lenalidomide ( Revlimid ), and pomalidomide ( pomalysts )

• bortezomib ( Velcade ) and carfilzomib ( kyprolis )
• Eribulin ( Halaven )

3 major agents: 1) platinum drugs, Taxanes and last vinka alkaloids

Question 21

Chemotherapy calculations
Based on BSA mg/mˆ2

Answer 21

mg/mˆ2

One inch = 2.54 cm
1kg = 2.2 pounds
BSA = √ [ height in cm x weight in kg ) / 3600 ]

Ex:
Doxorubicin dose: 60 mg / mˆ2
If BSA = 2 mˆ2
Dose= 120 mg

Question 22

General policy and procedures of making chemo therapy

Answer 22

Fan/blower and requirements: LAFW operated continuously 24 hours or on 30 mins prior to compounding
Certified hood every 6 months

Yellow sharps for chemo 2/3 full max
Eye protection/ 2 pairs of gloves. Zip log bag.
Vertical flow hood to protect techs.

Question 23

Alkylating agents

Answer 23

•cisplatin, carboplatin, oxaliplatin
• busulfan
• cyclophosphamide, Ifosphamide, Temozolomide = hepatotoxicity
• carmustine, lomustine
• streptozocin
• melphalan, mechlorethamine, altretamine,
• Dacarbazine, Procarbazine,
• Bendamustine ( Treanda )
- an alkylating agent for tx of chronic lymphocytic leukemia

Question 24

Antimetabolites

Answer 24

•MTX methotrexate
• Fluorouracil ( 5-FU )
• Mercaptopurine ( 6-MP )
• Cytarbine, fludarbine, capecitabine, cladribine
• Pentostatin
• Thioguanine
• Hydroxyurea

Question 25

ABX

Answer 25

• bleomycin
• dactinomycin, Daunorubicin, valrubicin,
•doxorubicin liposomal / non-liposomal
•epirubicin, idarubicin
•mitomycin, Plicamycin
• Mitoxantrone *
• idarubicin

Question 26

Plant alkaloids

Answer 26

Docetaxel, Paclitaxel
Etoposide, Teniposide
Irinotecan, Topotecan

Tax= you know if you see that it’ll cause peripheral neuropathy

Question 27

Cisplatin

Answer 27

Platinol

Nephrotoxic : give IV fluid, ( amifostine) given prophylactically to prevent nephrotoxicity ) and give mannitol to promote excretion
OTOTOXICITY ( dont give with vanco , aminoglycoside )
Peripheral neuropathy

this agent cause most GI upset

Question 28

Mannitol
Amifostine

Answer 28

Osmotic diuretic ( if you see crystals in mannitol, warm it up , shake and it’ll dissolve )
Amifostine ( Ethyol ) start before chemo. SE: decreases pt BP

Question 29

Carboplatin ( paraplatin )

Answer 29

Analog of cisplatin

Question 30

BuSulfan

Answer 30

Busulfex; myleran )

Increases : uric acid use allopurinol ( watch out for other drugs thiazide & loops, niacin , asa )
Pulmonary fibrosis
Seizures , skin rash, bone marrow Suppression

Question 31

Cyclophosphamide

Answer 31

( Cytoxan )
PO and IV

Hemorrhagic cystitis ( shedding of the bladder from metabolite acrelein ) give prophylactic MESNA ( binds to acrolein )

Heptoxic, renal tubular necrosis, alopecia ( frequent . 3 weeks after therapy )

Question 32

Ifosfamide

Answer 32

IFEX ( IV )

Analog of cyclophosphamide

Use hydration and MESNA to protect bladder

Alopecia, CNS tox, nephrotox

Question 33

Carmustine
And
Lomustine

Answer 33

Carmustine ( BiCNU) / Lomustine ( CeeNu / Gleostine )

Pulmonary fibrosis
- dose related. Can happen years later.

Hepatotox, nephrotox

Question 34

Streptozocin

Melphalan

Answer 34

IV Zanosar to treat pancreatic cancer
SE: dose response: type 1 DM

Melphalan IV PO : ( alkeran )
Use within 60 mins of reconstitution

Question 35

Mechlorethamine

Answer 35

( mustargen, Valchlor )

IV: mustargen
- extravasation associated with severe necrosis. Treat with Na - thiosulfate and ice compress. ( recall nitroprusside hypertensive emergency , nitroprusside can cause cyanide toxicity and for that toxicity we can use sodium thiosulfate )

Topical gel : Valchlor

Fertility impairment : Rph should not work with these meds if desiring to get pregnant

Question 36

Altretamine

Answer 36

( hexalen )
Perpheral neuropathy
Used to treat ovarian cancer

If you add MAOI ( lenazolid, nardil ) may cause severe orthostatic hypotension

Question 37

Procarbazine

Answer 37

Matulane

Is an MAOI.
Disulfiram like reaction

Question 38

Bendamustine

Answer 38

( treanda )
IV
Make with NS

SE : myelosuprresion - infections

Tumor lysis syndrome
Allopurinol : purine in there can cause rash.