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Hem/Onc Module > EXAM TWO > Flashcards

EXAM TWO Flashcards

1
Q

What are the 3 types of Oncologic Emergencies?

A
  1. Metabolic
  2. Structural
  3. Hematologic
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2
Q

What is Tumor Lysis Syndrome TLS?

A

Release of intracellular components into the bloodstream following cell lysis = metabolic abnormalities

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3
Q

Define Hyperuricemia

A

Uric Acid >8 mg/dL or 25% increase from baseline

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4
Q

Define Hyperkalemia

A

Potassium >6 mEq/L or 25% increase from baseline

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5
Q

Define Hyperphosphatemia

A

Phosphorous >6.5 mg/dL or 25% increase from baseline

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6
Q

Define Hypocalemia

A

Calcium <7 mg/dL or 25% decrease from baseline

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7
Q

What are the Risk Factors for TLS?

A
  1. Uric Acid >8 mg/dL at baseline
  2. Allergy to Allopurinol
  3. WBC >50,000
  4. LDH >500 units
  5. Creatinine >1.8
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8
Q

What is the presentation of Hyperkalemia?

A
  1. Muscle Cramps/Weakness
  2. N/V/D
  3. EKG Changes/Arrhythmias
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9
Q

What is the presentation of Hyperuricemia?

A

Acute Renal Failure

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10
Q

What is the presentation of Hyperphosphatemia?

A
  1. Muscle Cramps
  2. Seizures
  3. Arrhythmias
  4. Renal Failure
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11
Q

What is the presentation of Hypocalcemia?

A
  1. Muscle Cramps
  2. Tetany
  3. Mental Status Changes
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12
Q

What 4 things can be considered in the Prevention of TLS?

A
  1. Agressive IV Fluid Hydration
  2. Close Electrolyte Monitoring
  3. Discontinue Contributing Agents
  4. +/- Anti-Hyperuricemic Agents
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13
Q

Aggressive IV Fluid Hydration in Prevention of TLS includes what?

A

Normal Saline 2-3 L/m2/day for 1-2 days prior to therapy

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14
Q

Step 3 of Preventing TLS is to DC Contributing Agents, list all agents:

A
  1. ACE/ARBs
  2. Diuretics
  3. Potassium Chloride
  4. Sodium Phosphate
  5. Supplements/Vitamins
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15
Q

Low Risk of TLS +/- Anti-Hyperuricemic Agents

A
  1. Hydration
  2. Clinical Consideration
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16
Q

Intermediate Risk of TLS +/- Anti-Hyperuricemic Agents

A
  1. Hydration
  2. Allopurinol
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17
Q

High Risk of TLS +/- Anti-Hyperuricemic Agents

A
  1. Hydration
  2. Rasburicase
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18
Q

Hyperuricemia is the most common lab finding for TLS and prevention is aimed here, when does it usually occur?

A

48-72 hours after treatment

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19
Q

What are the 2 Antihyperuricemic Agents?

A
  1. Allopurinol
  2. Rasburicase
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20
Q

Allopurinol Indication and MOA

A
  1. PREVENTION ONLY
  2. Xanthine Oxidase Inhibitor: prevents formation of more uric acid, does not decrease the amount already present
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21
Q

Allopurinol AEs and Max Dose

A
  1. Rash
  2. Urticaria
  3. MAX = 800 mg/day
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22
Q

Rasburicase Indication and MOA

A
  1. Prevention AND Treatment
  2. Recombinate Urate Oxidase: breaks down uric acid into allantoin
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23
Q

Rasburicase AEs

A
  1. Hypersensitivity
  2. Methemoglobinemia
  3. Headache
  4. Peripheral Edema
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24
Q

Hyperkalemia is an Immediate Threat because it can lead to cardiac death, when does it occur?

A

6-72 hours, EKG changes

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25
Q

What is used to Stabilize the Heart with Hyperkalemia?

A
  1. Calcium Gluconate, it does NOT lower potassium levels, works within 30-60 mins to stabilize heart
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26
Q

What 3 Drugs can be used as Cation Exchange Resins to get rid of K+?

A
  1. Sodium Polystyrene Sulfate
  2. Patiromer/Veltassa
  3. Zicronium/Lokelma
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27
Q

What is the K+ Lowering Ranges of the 3 Cation Exchange Resin Drugs?

A
  1. Sodium Polystyrene Sulfate = 1 mEq
  2. Patiromer/Veltassa = 0.5-1 mEq
  3. Zicronium/Lokelma = 0.7 mEq
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28
Q

What other 2 MISC Agents can be used for Hyperkalemia?

A
  1. Dextrose 50% + Insulin
  2. Beta Agonist
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29
Q

How does Dextrose 50% + Insulin work for treatment of Hyperkalemia? How much K+ Lowering does it do?

A
  1. Shifts K+ Intracellularly
  2. 0.5 - 1.2 mEq/L
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30
Q

What are the treatment options for Hyperphosphatemia?

A
  1. Restrict Phosphate Containing Food
  2. Phosphate Binders
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31
Q

List the Phosphate Binders

A
  1. Aluminum Hydroxide
  2. Sevelamer/Renagel
  3. Calcium Acetate/PhosLo
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32
Q

What are the treatment options for Hypocalcemia?

A
  1. Fix the Phosphate
  2. Calcium Gluconate ONLY if Symptomatic
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33
Q

Calcium Homeostasis involves what organs?

A
  1. GI Tract
  2. Bone
  3. Kidneys
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34
Q

What is the Stimulus and Result relating to Parathyroid Hormone PTH?

A

Stimulus: Decreased Calcium
Result: Increased Calcium

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35
Q

What is the Stimulus and Result relating to Calcitriol?

A

Stimulus: Increase PTH
Result: Increase Calcium

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36
Q

What is the Stimulus and Result relating to Calcitonin?

A

Stimulus: Increase Calcium
Result: Decrease Calcium

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37
Q

What is the formula for Corrected Calcium?

A

Corrected Calcium = Measured Calcium + [ 0.8 x (4-albumin)]

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38
Q

What are the ranges of Hypercalcemia using Corrected Calcium values?

A

MILD = <12 – only treat if symptomatic
MOD = 12 - 13.9 – usually treated
SEVERE = >14 – immediately treated

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39
Q

What are the Symptoms of Hypercalcemia?

A
  1. Painful Bones
  2. Renal Stones
  3. Abdominal Groans
  4. Psychic Moans
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40
Q

What are the Principles of Treatment for Hypercalcemia?

A
  1. Rehydration/Secretion
  2. Stop Bone Resorption
  3. Treat Underlying Causes
  4. Remove Exogenous Sources of Calcium
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41
Q

What are the agents used for Hypercalcemia?

A
  1. Hydration
  2. Diuretics: specifically those that cause hypocalcemia
  3. Bisphosphonates
  4. Calcitonin
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42
Q

Causes of Hypercalcemia: VITAMIN, know N

A

V: vitamin A/D
I: immobilizaiton
T: thyrotoxicosis
A: addison’s
M: milk
I: inflammatory disorders
N: NEOPLASTIC DISEASES

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43
Q

Causes of Hypercalcemia: STRAP, know T/R

A

S: sarcoidosis
T: THIAZIDES, other drugs
R: RENAL FAILURE, rhabdomyolysis
A: aids
P: parathyroid disease

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44
Q

What is initial acute therapy for Hypercalcemia? And how does it work?

A
  1. Fluids: dilution effect as dehydration is corrected, helps increase renal calcium excretion
  2. Diuretics: increases urinary excretion of calcium
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45
Q

Can diuretics be given as mono therapy for Hypercalcemia T/F?

A

False, must be given with fluids

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46
Q

IV Bisphosphonates and RANK Ligand Inhibitors are utilized as management of Hypercalcemia, but are NOT acute therapy. When should they be administered?

A

The SAME time as acute treatment since they have a LONG onset

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47
Q

List IV Bisphosphonates used for Hypercalcemia and their MOA

A
  1. Zolendronic Acid
  2. Pamidronate
    Inhibits osteoclastic bone resorption
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48
Q

List RANK Ligand Inhibitors used for Hypercalcemia and their MOA

A
  1. Denosumab
    Inhibits RANKL resulting in inhibition of osteoclast recruitment, maturation, and action
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49
Q

What are the AEs of IV Bisphosphonates?

A
  1. Nephrotoxic
  2. Osteonecrosis of the Jaw
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50
Q

What are the AEs of RANK Ligand Inhibitors?

A
  1. Osteonecrosis of the jaw
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51
Q

What is used ACTUELY for Severe cases of Hypercalcemia? And what it is the AEs?

A
  1. Calcitonin: adjust therapy only use in symptomatic patients
    -Tachyphylaxis, MAX 8 DOSES
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52
Q

What is the treatment of Mild Hypercalcemia Asymptomatic?

A
  1. Increase fluid intake
  2. Stop offending drugs
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53
Q

What are offending drugs in Hypercalcemia?

A
  1. Calcium supplements
  2. Thiazide diuretics
  3. Vitamin D
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54
Q

What is the treatment of Mild Hypercalcemia Symptomatic?

A
  1. Hydration
  2. +/- loop diuretics after hydration
  3. Consider IV bisphosphonates
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55
Q

What is the treatment of Moderate Hypercalcemia?

A
  1. Hydration
  2. +/- Loop diuretics after hydration
  3. IV Bisphosphonates
  4. Consider calcitonin
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56
Q

What is the treatment of Severe Hypercalcemia?

A
  1. Hydration
  2. +/- Loop diuretics after rehydration
  3. IV Bisphosphonates
  4. Calcitonin
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57
Q

What is Refractory Hypercalcemia?

A

If calcium levels remain elevated after 2 doses of bisphophonate

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58
Q

What can be considered in Refractory Hypercalcemia?

A
  1. Steroids
  2. Denosumab
  3. Dialysis
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59
Q

Neutropenic Fever is considered a medical emergency, why?

A

Neutropenic patients are at a higher risk for serious infections, fever is only a sign of infection

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60
Q

What is Nadir?

A

Lowest point of WBC possible

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61
Q

When does Neutropenia usually occur?

A

10-14 days of chemotherapy administration

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62
Q

Fever occurs >80% during chemotherapy induced neutropenia from what type of cancers?

A

Hematologic Malignancies

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63
Q

What are the 3 common sites for tissue-based infection?

A
  1. Intestinal Tract
  2. Lungs
  3. Skin
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64
Q

What are the 3 main components in the initial patient workup?

A
  1. H&P
  2. Vitals
  3. Medications
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65
Q

What is the Outpatient Treatment Criteria?

A
  1. No critical lab values
  2. Able to swallow PO meds
  3. Psychosocial/Logistic Requirement
  4. Prior FQ prophylaxis
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66
Q

Define Neutropenic Fever

A
  1. Single temperature equivalent to >38.3C (101F) orally
  2. Temperature >38C (100.4F) orally, sustained over 1 hour period
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67
Q

Define Neutropenia

A
  1. ANC <500 neutrophils/uL
  2. ANC <1000 neutrophils/uL and a predicted decline to <500/uL over next 48 hours
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68
Q

Define Prolonged Neutropenia

A

> 7 days

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69
Q

Define Profound Neutropenia

A

<100 neutrophils/uL

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70
Q

How do you calculate Absolute Neutrophil Count ANC?

A

[(WBC) x (% segments + % bands)]/100

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71
Q

What is the most common Outpatient Treatment of Neutropenic Fever?

A

Ciprofloxacin or Levofloxacin + Augmentin

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72
Q

What is used in Outpatient Treatment of Neutropenic Fever with Severe Penicillin Allergy?

A

Clindamycin + FQ

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73
Q

What is most commonly used for Inpatient Empiric Treatment of Neutropenic Fever?

A
  1. Cefepime
  2. Pip/Taz
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74
Q

IV Antibiotic Therapy for Inpatient Empiric Treatment of Neutropenic Fever must be started when?

A

Within 1 hour of patient presentation

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75
Q

If the patient has a severe beta-lactam allergy, what would inpatient therapy be for neutropenic fever?

A
  1. Vanco
  2. Azetreonam
  3. ID Consult
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76
Q

Cefepime has good CNS penetration and what?

A

NO anaerobic coverage

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77
Q

Does Zosyn have anaerobic coverage?

A

Yes

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78
Q

Ceftazidime has weak gram positive and no anaerobic coverage, it also has higher resistance with what?

A

Higher resistance with gram neg

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79
Q

Should Vancomycin be used in routine empiric IV coverage of Neutropenic Coverage?

A

NO, but can be used it needed for gram pos pathogen must reassess in 2-3 days

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80
Q

Is double coverage for gram negatives routinely recommended in Neutropenic Fever treatment?

A

NO

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81
Q

When would double coverage be necessary in Neutropenic Fever treatment?

A
  1. Higher risk or resistant cases
  2. High local resistance rates
  3. History of previous psudeomonas infections
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82
Q

When would you need additional gram + coverage for Neutropenic Fever?

A
  1. Pneumonia
  2. Cellulitis/SSTI
  3. Device/Line Inflammation
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83
Q

When would you need additional anaerobic coverage for Neutropenic Fever?

A
  1. Oral/GI Involvement
  2. Abdominal Symptoms
  3. Peri-Rectal Pain
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84
Q

When would you need additional fungal coverage for Neutropenic Fever?

A
  1. Thrush
  2. Invasive Fungus
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85
Q

When would you need additional antiviral coverage for Neutropenic Fever?

A
  1. Vesicular Lesions
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86
Q

What would you need to do in terms of diarrhea for Neutropenic Fever patients?

A
  1. C. diff testing
  2. Fidaxomicin or PO Vancomycin
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87
Q

Treatment Modification After Initial Presentation: Low Risk Inpatient, Clinically Stable, and Adequate GI Absorption

A

IV –> PO

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88
Q

Treatment Modification After Initial Presentation: Etiology Identified

A

Treat Per Infection

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89
Q

Treatment Modification After Initial Presentation: Persistently Febrile

A

Broaden Coverage and Continue Fever Workup

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90
Q

When should you consider empiric treatment for Antifungal in Neutropenic Fevers?

A

Consider addition if >4days of empiric antibiotics in high-risk patients with no symptom improvement

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91
Q

What are the risk factors related to Fungal Neutropenic Fevers?

A
  1. Neutropenia >10 days
  2. Allogeneic HCT Recipients
  3. High dose corticosteroids
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92
Q

If a patient is receiving Fluconazole for anti-yeast prophylaxis what should it be changed to?

A

Change to empirical anti fungal with mold coverage

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93
Q

If a patient is receiving Anti-Mold prophylaxis what should it be changed to?

A

Consider switch to alternative anti fungal with mold coverage

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94
Q

What drugs are consider antifungals?

A
  1. Triazoles
  2. Amphotericin B
  3. Micafungin
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95
Q

List all the Triazoles

A
  1. Fluconazole
  2. Itraconzaole
  3. Voriconazole
  4. Posaconazole
  5. Isavuconazole
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96
Q

Fluconazole is NOT active against what?

97
Q

Itraconzole has what CI?

A

Significant cardiac systolic dysfunction

98
Q

Voriconazole has an AE of visual disturbances/hallucinations but what is it’s caution?

A

Hepatic Impairment

99
Q

Isavuconazole should be considered if intolerant or refractory to first line therapy, but what is it’s main concern?

A

Can SHORTEN QTc

100
Q

Amphotericin has what 2 concerns?

A
  1. Renal Toxicity
  2. Electrolyte Wasting (K+/Mg2+)
101
Q

Micafungin has a great safety profile but POOR penetration in what 3 areas?

A
  1. CNS
  2. Urinary Tract
  3. Eye Penetration
102
Q

What are the outpatient treatment options for Covid-19?

A
  1. Paxlovid
  2. Remdesivir
  3. Molnupravir
103
Q

What are the inpatient treatment options for Covid-19?

A
  1. Remdesivir +/- Dexamethasone
  2. Immunomodulator Agents
  3. Convalescent Plasma
104
Q

What are the treatment options for HSV/VZV?

A
  1. Acyclovir
  2. or Valacyclovir
105
Q

What are the treatment options for HSV/VZV/CMV?

A
  1. Ganciclovir
  2. or Valganciclovir
    BOTH cause bone marrow suppression
106
Q

Duration Consideration: Afebrile + ANC >500

A

DC therapy

107
Q

Duration Consideration: Afebrile + ANC <500

A

Continue, DC, or move to prophylaxis

108
Q

Duration Consideration: Documented Infection

A

Treat pathogen

109
Q

Duration Consideration: Febrile, no known source

A

Patient Factors

110
Q

What is the Duration Treatment for Skin/Soft Tissue Bacterial Pneumonia?

111
Q

What is the Duration Treatment for Uncomplicated Bacteremia?

112
Q

What is the Duration Treatment for S.Aureus Bacteremia?

113
Q

What is the Duration Treatment for Sinusitis?

114
Q

What is the Duration Treatment for Candida?

A

Minimum 2 weeks after 1st neg blood culture

115
Q

What is the Duration Treatment for Molds?

A

Minimum 12 weeks

116
Q

What is the Duration Treatment for HSV/VSV?

117
Q

What is the Duration Treatment for Influenza?

A

Minimum 5 days

118
Q

What is the preferred agent for Prophylaxis of Neutropenic Fever: Antibacterial?

A

Levofloxacin

119
Q

What is the preferred agent for Prophylaxis of Neutropenic Fever: Antiviral?

A

Acyclovir or Valacyclovir

120
Q

What is the preferred agent for Prophylaxis of Neutropenic Fever: Antifungal?

A

Fluconazole or Posaconazole

121
Q

What is the preferred agent for Prophylaxis of Neutropenic Fever: Anti-Pneumocystis PJP?

122
Q

Myelosuppression is the most common __ __ side effect and the most common site of toxicity is the __ __.

A
  1. Dose-Limiting
  2. Bone Marrow
123
Q

What chemotherapy drugs do NOT cause myelosuppression?

A
  1. Vincristine
  2. Bleomycin
  3. Hormones
  4. Corticosteroids
  5. L-Asparaginase
  6. Intergerons
  7. Methotrexate + Leucovorin Rescue
124
Q

What drugs are eliminated Renally?

A
  1. Cisplatin
  2. Carboplatin
  3. Methotrexate
  4. Topotecan
125
Q

What drugs are eliminated Hepatically?

A
  1. Anthracyclines
  2. Vinca Alkaloids
  3. Taxanes
  4. Irinotecan
126
Q

What drug is Renal Toxic?

127
Q

What is the most common cause of treatment delay and dose reductions in chemotherapy?

A

Neutropenia

128
Q

What is the Primary Prevention for Neutropenia?

A
  1. Prophylatic Granulocyte Colony-Stimulating Factors (G-CSFs) of treatment at REDUCED dose
  2. Given at FIRST DOSE of chemo
129
Q

What is the Secondary Prevention for Neutropenia?

A
  1. Measures taken to prevent neutropenia from reoccurring with subsequent courses
  2. Dose Reduction or Prophylatic G-CSFs
130
Q

When should G-CSFs be used for primary prophylaxis of neutropenia?

A
  1. Required and Recommended for Dose DENSE regimens
  2. Risk of neutropenic fever >20%
  3. Recommended for high risk patients
131
Q

Is G-CSF useful in the treatment of Neutropenia?

A

NO, more effective in prophylaxis than treatment

132
Q

G-CSF Prophylaxis Dosing Schedule

A

ALL must be given >24 hrs but <72 hrs after chemotherapy

133
Q

Pegfilgrastim (G-CSF) Dosing

A
  1. SINGLE DOSE
  2. Start 1-2 days after completion of chemotherapy
134
Q

What is the MOST common toxicity with G-CSFs?

135
Q

What drugs are MOST commonly associated with thrombocytopenia?

A
  1. Topotecan
  2. Carboplatin
  3. Gemcitabine
  4. Bortezombi
136
Q

What is the treatment for Established Thrombocytopenia?

A

Platelet transfusions for platelet counts <10,0000 or <50,000 with active bleeding

137
Q

Define Anemia

A

Hemoglobin <11 g/dL or >2 g/dL below baseline

138
Q

Anemia is common with what two marrow toxic agents?

A
  1. Docetaxel
  2. Carboplatin
139
Q

What is used for management of Anemia?

A
  1. Epoetin Alfa
  2. Darbepoetin Alfa
140
Q

What are the risks associated with giving ESAs?

A
  1. Increased risk of thrombosis and hypertension
  2. Increased risk of mortality in patients with cancer
  3. Risk of tumor progression
141
Q

ESAs should NOT be used when?

A

When treatment intent is CURATIVE

142
Q

When should ESAs be used in chemotherapy patients?

A

Used in chemotherapy-induced anemia and DC once chemotherapy is complete

143
Q

Define Direct Stomatoxicity Mucositis

A

Due to cytotoxic agents

144
Q

Define Indirect Stomatoxicity Mucositis

A

Due to concurrent neutropenia thrombocytopenia

145
Q

List the Agents that are associated with Mucositis

A
  1. 5-Fluorouracil
  2. Methotrexate
  3. Doxorubicin
  4. Pemetrexed
  5. Stem Cell Transplantation Process
146
Q

What is used in Mucostitis Prevention?

A
  1. Oral hygiene
  2. Palifermin/Kepivance
147
Q

What is Palifermin (Kepivance)?

A
  1. Human keratinocyte growth factor
  2. Indicated for prevention of mucositis following chemotherapy in patients requiring stem cell transplant
148
Q

What patients are at the highest risk for diarrhea from chemotherapy?

A

Elderly and Females

149
Q

What chemotherapy agents are known to cause diarrhea? (I ran to the can)

A
  1. 5-FU and Capecitabine
  2. Immunotherapy
  3. Irinotecan
150
Q

What can be used for prevention of diarrhea in chemotherapy?

A
  1. Atropine for Irinotecan
151
Q

What can be used for treatment of Diarrhea in Chemotherapy?

A
  1. Loperamide: NOT safe in immunotherapy
  2. Octreotide: SEVERE patients
152
Q

What drug is the “poster child” for Diarrhea association?

A

Irinotecan

153
Q

What should be given for Irinotecan Early Onset Diarrhea that occurs during or within hours of infusion?

A

Atropine 0.25-1 mg SQ or IV

154
Q

What should be given for Irinotecan Late Onset Diarrhea that occurs >12 hrs after drug administration?

A

HIGH dose Loperamide

155
Q

What genetic deficiency leads to worse diarrhea and neutropenia with Irinotecan?

A

Homozygous UGT1A1

156
Q

What chemotherapy agents most commonly cause Constipation?

A
  1. Vinca Alkaloids –> especially VINCRISTINE
157
Q

What is used for prevention of Chemotherapy Induced Constipation?

A
  1. Stool Softeners
  2. Laxatives
158
Q

What can be used for treatment of Chemotherapy Induced Constipation?

A
  1. Enema
  2. PAMORA: Methylnaltrexone
159
Q

What are appetite stimulants that can be used for chemotherapy induced Anorexia and Cachexia?

A
  1. Megestrol Acetate
  2. Corticosteroids
  3. Olanzapine
  4. Dronabinol
160
Q

What chemotherapy agents are known to cause Cardiac Toxicity?

A
  1. Anthracyclines
    -Doxorubicin
    -Daunorubicin
    -Idarubicin
  2. HER2 Targeted Agents
    -Trastuzumab
161
Q

How does Anthracyclines cause Cardiac Toxicity?

A

Free Radicals + Iron Combo cause direct damage to myocardial tissue

162
Q

What is the main consequence for use of Anthracyclines?

A

CHF 5-10 yrs after treatment

163
Q

What 4 things should be done to prevent Cardiac Toxicity with Anthracyclines?

A
  1. Baseline MUGA with EF>50%
  2. Prolong Infusion
  3. Limit Total Cumulative Dose
  4. Dexrazoxone
164
Q

What is the MAX lifetime dose for Doxorubicin and Daunorubicin?

165
Q

What is Dexrazoxane (Zinecard)?

A

Metachelator that strips Doxorubicin from Iron Complexes and prevents generation of free oxygen radicals

166
Q

Dexrazoxane protects against anthracycline induced cardiomyopathy but use limited to patients with what?

A

Advanced Breast Disease who have received >300 mg/m2 of Doxorubicin

167
Q

Trastuzumab can cause Cardiac Toxicity however, it is different from Anthracyclines how?

A

Reversible cardiac toxicity, anthracyclines = permanent

168
Q

What agent is known to cause Pulmonary Toxicity?

169
Q

What is used to treat Pulmonary Toxicity?

170
Q

What agents are known cause Renal Toxicity?

A
  1. Cisplatin
  2. HIGH dose Methotrexate
171
Q

How can you prevent Renal Toxicity with Cisplatin?

A

Hydration with normal saline + electrolytes (K/Mg)

172
Q

What is the treatment for Renal Toxicity with Cisplatin or Methotrexate?

A
  1. Hydrations with normal saline
  2. DC nephrotoxins
173
Q

How can you prevent Renal Toxicity with Methotrexate?

A

Alkalinization of urine to PH >7

174
Q

What agents are known to cause Bladder Toxicity?

A
  1. Cyclophosphamide
  2. Ifosfamide
175
Q

How do the Nitrogen Mustard Alkylating Agents cause Bladder Toxicity?

A

Inactive metabolite Acrolein binds to and irritates blood vessels in bladder, leads to bleeding

176
Q

How do you prevent Bladder Toxicity caused by Ifosfamide?

A

Mensa: 20% of ifosfamide dose immediately before then 4 and 8 hrs after

177
Q

What is Mensa?

A

Protective Drug against Acrolein
Binds to acrolein in kidneys and bladder

178
Q

What agents are known to cause Neurotoxicites?

A
  1. Oxaliplatin: acute/chronic neuropathies
  2. Taxanes: peripheral neuropathy
179
Q

Peripheral Neuropathy Symptoms of Pain, Numbness, and Tingling are related to what drugs?

180
Q

What type of Oxaliplatin Neuropathy has peripheral symptoms exacerbated by COLD?

A

Acute = Reversible

181
Q

What type of Oxaliplatin Neuropathy has a dose adjustment approach as “stop and go”?

A

Chronic = Persistent >14 days

182
Q

List the 4 types of Dermatologic Toxicity

A
  1. Alopecia
  2. Photosensitivity
  3. Hand-Food Syndrome
  4. EGFR Inhibitor Skin Toxicity
183
Q

What are ways to manage EGFR-Associated Rash?

A
  1. Topical Corticosteroids if MILD
  2. Oral Antibiotics: doxycycline/minocycline
  3. Topical Antibiotics: clindamycin
  4. Systemic Corticosteroids if SEVERE
184
Q

Define Vesicants

A

Leakage of drug from the vein into the surrounding tissue resulting in necrosis

185
Q

What drugs are known Vesicants?

A
  1. Anthracyclines
  2. Vinca Alkaloids
  3. Nitrogen Mustards
  4. Mitomycin C
186
Q

Warm or Cold Compress for: Nitrogen Mustards?

187
Q

Warm or Cold Compress for: Vinca Alkaloids?

188
Q

Warm or Cold Compress for: Anthracyclines?

189
Q

What is Dexrazoxane (Totect)?

A

Indicated for treatment of extravasation resulting from IV anthracyclines chemotherapy

190
Q

How long should Dexrazoxane be used for?

A

Administered over 3 consecutive days

191
Q

What chemotherapy agents are known to cause Allergic Reactions?

A
  1. L-asparaginase
  2. Paclitaxel
  3. Bleomycin
  4. Carboplatin
  5. Cetuximab and other monoclonal antibodies
192
Q

What is used for prevention of hypersensitivity for Bleomycin and Cetuximab?

A

Test Doses

193
Q

What is used for prevention of hypersensitivity for Paclitaxel and Cetuximab?

A

Premedication

194
Q

Hypersensitivity of Paclitaxel is due to what?

A

Cremophor EL solubility vehicle

195
Q

What 3 drugs are used for Premedication?

A
  1. Dexamethasone
  2. Diphendramine
  3. Famotidine
196
Q

Ipilimumab CTLA-4 Inhibitor is known to have irAEs that are severe, what is the most common?

A

Diarrhea/Colitis

197
Q

Nivolumab, Pembrolizumab, Atezolizumab PD-1 Inhibitors are known to cause irAEs, what are the most common?

A

Endocrinopathies, Pneumonitis, Hepatitis, Colitis

198
Q

What side effect would NOT stop immunotherapy and be managed with separate medications?

A

Hypothyroidism
Give Levothyroxine

199
Q

What is the formula for Body Surface Area BSA?

A

square root [((height cm) x weight kg))/3600]

200
Q

What weight should be used for dosing in oncology?

201
Q

What is the dose limit of Vincristine due to Neurotoxicity?

202
Q

List Chemotherapy of the Order Components

A
  1. Name
  2. Drug Sequence
  3. Dose
  4. Rate and Route
203
Q

Drug Interactions Concerns: GI Absorption

A

Changes in pH d/t coadministration of H1 antagonists, PPIs, and antacids

204
Q

Drug Interactions Concerns: Transport and Metabolism

A

Intestinal transporters/enzymes
1. Pgp Pump
2. CYP3A4, 2C19

205
Q

Drug Interactions Concerns: Additive Toxicity

A

QTc prolongation

206
Q

Non-Melanoma Skin Cancer Treatment NMSC

A

Surgery > Systemic

207
Q

Melanoma Skin Cancer Treatment

A

Surgery +/- Systemic

208
Q

What is the etiology of Melanoma?

A

Direct damage to melanocytes in epidermis by UV (UVB>UVA) –> DNA Damage –> Somatic Mutations –> Uncontrolled Growth = Cancer

209
Q

What is the most common mutation in Melanoma?

A

MAPK/ERK Pathway

210
Q

Most melanoma’s start with a radial phase which is what?

A

Vertical Growth Phase

211
Q

What are the main targets for chemotherapy agents for Melanoma?

A
  1. PDL1
  2. PD1
  3. CTLA4
212
Q

What are the hallmark characteristics in changing nevous of Melanoma?

A
  1. Color
  2. Shape
  3. Borders
  4. Bleeding/Irritation
213
Q

What agents can be used for Systemic Therapy in Stage 1 Melanoma?

A

Pembrolizumab

214
Q

What agents can be used for Systemic Therapy in Stage III Melanoma?

A
  1. Pembrolizumab
  2. Nivolumab
  3. Dabrafenib/Trametinib
215
Q

What agents can be used for Systemic Therapy in Stage IV Melanoma?

A
  1. Ipilimumab/Nivolumab
  2. Nivolumab/Relatimab-rmbw
216
Q

What is the MOA of Pembrolizumab and Nivolumab?

A

Anti PD-1
-Inhibits T cell downregulation and decrease response

217
Q

What are the AEs of Pembrolizumab and Nivolumab?

A
  1. Rash, Diarrhea
  2. Hepatitis
  3. Myocarditis/Pericarditis
218
Q

What is the MOA of Dabrafenib and Trametinib?

A

BRAF and MEK Inhibitor Combo

219
Q

BRAF/MEK Inhibitor combos elicit response much faster than immunotherapy, what are their specific pearls?

A

Dabrafenib: take on empty stomach
Trametinib: protect from light

220
Q

What are the AEs of Dabrafenib and Trametinib?

A
  1. Pyrexia
  2. Skin Rash: SJS
  3. Hyperglycemia
221
Q

What is the emetic potential of Dabrafenib and Trametinib?

A

Dabrafenib = moderate
Trametinib = low

222
Q

What is the MOA and Dosing of the Ipi/Nivo Combination?

A

PD1 and CTLA4 Inhibitor
MAX 4 Cycles

223
Q

What is the MOA of Nivo/Relatilimab Combination?

A

Anti PD1 + Anti LAG3 = immunotherapy

224
Q

When comparing the combinations which has a lower reported ADR?

A

Nivo/Relatilimab

225
Q

If patient has Pyrexia, they must hold therapy and restart at what dose?

A

Restart at same dose upon resolution

226
Q

If patient’s has recurrent Pyrexia start what treatment?

A

Prednisone

227
Q

Skin Toxicity: Rash, Hives, and SJS is most common with what therapy?

A

BRAF Monotherapy

228
Q

Skin and GI toxicities are most common, however toxicity is more severe with what type of agents?

A

Combinations

229
Q

What is the therapy for Skin Immunotherapy Toxicity Grade 1?

A

Topical emollients and corticosteroids

230
Q

What is the therapy for Skin Immunotherapy Toxicity Grade 2?

A
  1. GI Management
  2. Consider holding therapy
  3. Consider 1 mg/kg oral prednisone + taper
231
Q

What is the therapy for Skin Immunotherapy Toxicity Grade 3?

A
  1. GI management
  2. Hold therapy
  3. 1-2 mg/kg methylprednisone + taper
232
Q

What is the therapy for Skin Immunotherapy Toxicity Grade 4?

A
  1. GI management
  2. Permanent dc
  3. 1-2 mg/kg methylprednisone + slow taper
233
Q

What is the therapy for GI Immunotherapy Toxicity Grade 1?

A

Consider holding therapy

234
Q

What is the therapy for GI Immunotherapy Toxicity Grade 2?

A
  1. Hold therapy
  2. 1 mg/kg prednisone + taper
235
Q

What is the therapy for GI Immunotherapy Toxicity Grade 3?

A
  1. Hold therapy
  2. Consider hospitalization
  3. 1-2 mg/kg prednisone + taper
  4. Consider IV for refractory
236
Q

What is the therapy for GI Immunotherapy Toxicity Grade 4?

A
  1. G3 management
  2. Permanent dc
  3. 1-2 mg/kg methylprednisone + slow taper
237
Q

What 3 things can be done to prevent cutaneous melanoma?

A
  1. Avoid direct exposure 10am - 4pm
  2. Avoid tanning beds
  3. Sunscreen SPF 15 or higher
238
Q

What is the identification principles of melanoma?

A

A = asymmetric
B = borders are irregular
C = color
D = diameter
E = evolving characteristics

Hem/Onc Module (5 decks)

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