Immune system and Malignancy Flashcards
What type of vaccines should be avoided in immunocompromised patients?
live
Examples of live vaccines
Measles, mumps, rubella (MMR combined vaccine)
Rotavirus
Smallpox
Chickenpox
Yellow fever
Nasal flu vaccine
What are immunosuppressants used for?
Suppress the immune system and chronic inflamation.
Examples of anti proliferative drugs?
azathioprine, mercaptopurine, mycophenolate
Examples of calcineurin inhibitors
tacrolimus, ciclosporin
What drugs are used in IBD?
Azathioprine, mercaptopurine, ciclosporin, methotrexate, corticosteroids
Azathioprine- MoA
blocks purine synthesis needed for DNA/RNA/protein synthesis
Azathioprine- side effects
blood disorders (leucopenia, thrombocytopenia, anaemia)
Pancreatitis
hypersensitivity
Nausea- take with food
Azathioprine- monitoring (pre-screening and general)
pre screening- TMPT testing
general - FBC (weekly for 4/8 weeks, then 3 monthly)
Azathioprine- counselling
report signs of blood disorders- unexplained bruising or bleeding and infections
If feeling nauseous then take with food
Azathioprine- interactions
ALLOPURINOL (azathioprine is metabolised by xanthines, allopurinol is a xanthine inhibitor)
- ACEi- increases risk of anaemia
- Trimethoprim- haem toxicity
- warfarin- decreases anticoagulant effect
How to deal with con-current use of azathioprine and allopurinol?
reduce to 1/4 of normal dose
Mycophenolate- MoA
blocks guanosine synthesis (purine) needed for DNA synthesis
Mycophenolate- side effects
blood disorders
hypogammaglobinemia
bronchiectasis, pulmonary fibrosis
GI effects (bleeding)
increases risk of skin cancer
Mycophenolate- counselling
report signs of infection/bleeding
report any new and persistent cough and SOB
avoid excessive exposure to sunlight
Mycophenolate- Cautions
recurrent infection
increased serum iG
persistent respiratory symptoms (cough,SOB)
Serious active GI disease- e.g. Ulcerative Colitis
Mycophenolate- Cautions
recurrent infection, increased serum iG
Mycophenolate- contraception requirements (women)
Women:
2 pregnancy tests before treatment
(8-10 days apart)
effective contraception until 6 weeks after stopping
must be part of the PPP
Mycophenolate- contraception requirements (men)
effective contraception until 90 after stopping
Tacrolimus- MoA
Calcineurin inhibitor (calcineurin activates T cells)
Tacrolimus- S/E
Blood disorders
Cardiomyopathy
nephrotoxicity
photosensitivity
HYPOKALAEMIA, Increased Glucose and urea
Tacrolimus- monitoring
Echo- hypertrophic changes (heart muscle becomes enlarged)
Tacrolimus- counselling
avoid excess UV exposure
blood disorders
report any palpitations, SOB, chest pain (hyperK)
Tacrolimus and ciclosporin- interactions
- Enz inhibitors (toxicity)
- Enz inducers
- Nephrotoxic drugs- aminoglycosides, glycopeptides, Ciclosporin, methotrexate, NSAIDs
- Hyperkalaemia- ACE/ARB, K-sparing, MRA, NSAID, Trimethoprim. Heparin
Tacrolimus- MHRA advice
brand continuity
Tacrolimus/sirolimus- what ethnicity may require an increased dose?
black African or African–Caribbean
Tacrolimus- monitoring
Whole-blood tacrolimus trough concentration
ECG
BP
Fasting blood glucose (causes increased glucose)
FBC
U&Es (creatinine)
Tacrolimus- contraception
exclude before treatment
Ciclosporin- MoA
calcineurin inhibitor
Ciclosporin- S/E
Eye inflammation/visual disturbances
gingival hyperplasia
nephrotoxicity
hyperkalaemia
Ciclosporin- what food/drinks should be avoided
pomelo and grapefruit juice- enz inhibitor
purple grape juice- enz inducer
Ciclosporin- monitoring
U&Es- potassium and magnesium (exam q- hyperkalaemia and hypomagnesaemia)
LFT- concurrent NSAIDS
FBC
lipids- before and 1 month after
BP- discontinue if uncontrolled
Why are cytotoxic treatments used
curative, prolong life and palliate symptoms
When can cytotoxics be used?
Neoadjuvant- before surgery or chemotherapy to shrink tumour
adjuvant- added to radiotherapy/surgery to maximise treatment effects
ADV/DISADV of 1 or more cytotoxic
ADV- reduces drug resistance, increased survival rate
DISADV- toxicity (increased supression)
Handling of cytotoxics (azathioprine, mercaptopurine, IV cytotoxics, finasteride)
- pregnant staff should avoid
- dedicated area of pharmacy
- trained staff
- spills and waste disposal procedure in place
- protective gear should be worn
-staff exposure should be monitored
What is required for the prescribing, dispensing and administration of cytotoxic drugs?
a written protocol or treatment plan
What cytotoxics commonly cause: VTE
Tamoxifen, thalidomide, linadmonide, pomalidomide
What cytotoxics can cause: endometrial cancer
tamoxifen
What cytotoxics commonly cause: Urethral toxicity
Cyclophosphamide, infosfamide (exam q)
TREAT WITH MESNA
What cytotoxics commonly cause: extravasation
vinca alkaloids, anthracyclines
What cytotoxics commonly cause: infertility in men
alkalating drugs and procarbozine
What are the 2 cytotoxics that do not cause bone marrow supression?
vincristine and bleomycin
What cytotoxics commonly cause: oral mucocytis
fluorouracil, methotrexate, anthracyclines
Bone marrow suppression:
treatment of fever and neutropenia
figrastim
Bone marrow suppression:
treatment of symptomatic iron deficiency anaemia
RBC transfusion
erythropoetin
Hyperuricaemia (common in lymphoma and leukaemia):
Treatment
allopurinol (24hours before chemo)
febuxostat (2 days before chemo)
rasburicase (haem cancers)
N&V
Mildly emetogenic
Methotrexate
vinca alkaloids
flurouracil
etoposide
N&V
moderate emetogenic
high dose MTX
Taxanes
Doxorubicin
Cyclophosphamide
mitoxantrone
N&V
Highly emetogenic
Cisplatin
Dacarbazine
High dose cyclophosphamide
N&V treatment:
Anticipatory
lorazepam
N&V treatment:
Acute <24 hours
Low risk: Dexamethasone or Lorazepam
High risk: Dex+ ondansetron + Aprepitant
N&V treatment:
Delayed
mod emetogenic= Dex + 5 HT3
High = Dex and Aprepitatn
or Rolapitant and metoclopramide
Vinca Alkaloids- what route should be avoided
intrathecal (neurotoxicity)
Vinca Alkaloids (vincristine side effects)
bronchospasm and neurotoxicity
What is given for the treatment of methotrexate induced oral mucositis
folinic acid (calium folate)
What form of treatment must be avoided with anthracyclines
radiotherapy
Examples of anthracyclines
Xrubicin
doxorubicin, daunorubicin, epirubicin, Idarubicin
Side effects of anthracyclines
red urine and caridotoxicity
Example of an anthracycline derivative
mitoxantrone
examples of alkylating drugs?
Cyclophosphamide, Ifosfamide, melphalan,
Methotrexate- Side effects
Blood disorders
liver toxicity
Respiratory effects- pneumonitis (cough (lasting weeks), SOB, weight loss)
nephrotoxicity
Methotrexate- monitoring
FBC and renal and LFTs repeated every 1–2 weeks until therapy stabilised, thereafter patients should be monitored every 2–3 months.
What OTC products should be avoided with methotrexate
NSAIDs, aspirin
penicillins, PPIs
statins
most antibiotics
TRIMETHOPRIM
what drugs are used in MS?
interferon beta
Glatiramer acetate
fingolimod (PO, highly active disease)
Natalizumab (rapidly evolving severe MS)
what drugs are used in breast cancer?
Early and locally advanced= tamoxifen
If patient declines chemotherapy= goserelin
Anastrozole and letrozole (Aromatase inhibitors)
What is used in advanced breast cancers
- endocrine therapy- tamoxifen
- Aromatase inhibitors (Anastrozole and letrozole & exemestane)
