Immune system and malignant disease Flashcards
Why do we give folic acid and how often to patients on methotrexate?
To reduce the possibility of methotrexate toxicity (unlicensed)
Give weekly on different days
Example of Antiproliferate Immunosuppresant
Azathioprine
Mycophenolate
Indication of Azathioprine
IBD. RA, autoimmune condition, suppression of transplant rejection, severe refractory eczema
Important interaction of Azathioprine
Increases the risk of haematological toxicity when given with allopurinol
Reduce the dose of Azathioprine to 1/4 when given with allopurinol
Azathioprine is broken down into
MERCAPTOPURINE
Side effect of Azathioprine
Bone marrow depression, increased risk of infection, leucopenia, thrombocytopenia, pancreatitis.
Nausea
Neutropenia and thrombocytopenia
Side effect of Azathioprine may require drug withdrawal. True/false
True
Side effect of Azathioprine that requires immediate withdrawal
Hypersensitivity rxn such as Dizziness, malaise, rash, N andV, fever
All immuosupressant are teratogenic. True/false
True
Azathioprine pre treatment screening
TPMT enzyme metabolises thiopurine drugs
AbsentTPMT activity- Don’t give thiopurine drugs
Reduced TPMT activity- treat under specialist care
Risk of myelosuppression increases in patients with reduced TPMT activity on Azathioprine. True/false
True
List examples of thiopurine
Tioguanine
Mercaptopurine
Azathioprine
Patient and carer advice for Azathioprine
Report any signs of bone Marrow suppression such as inexplicable bruising or bleeding, infection
Facts about Mycophenolate
Metabolised to mycophenolic acid
More selective MOA than Azathioprine
Incorporating Azathioprine and mycophenolate reduces risk of rejection but higher risk of blood disorder and infection
Caution with mycophenolate
Increased risk of skin cancer ( avoid exposure to strong sunlight)
Risk
Risk of hypogammaglobulinaemia ) ( low antibodies production) or bronchiectasis ( abnormal widening of the bronchi leading to infection when used in combination with other immunosuppresant
State what to do if recurrent infections develop when taking mycophenolate
Measure serum immunoglobulin levels
Consider bronchiectasis or pulmonary fibrosis if persistent respiratory symptoms eh cough and dyspnoea
Conception and contraception with mycophenolate
MHRA advises to exclude pregnancy in women of child bearing potential before treatment
2 pregnancy test 8-10days apart are recommended
Women should use atleast 1 method of contraception before and during tx and for 6weeks after discontinuation
Two method of contraception preferred
How.long should male patients and their partners use contraception while on mycophenolate
During tx and for 90days after discontinuation
Patients and carer advice while on mycophenolate
Warn patients to report any signs of bone marrow suppression eg infections, bruising or bleeding
Female patients should be part of PPP
Facts about corticosteroids in immunosuppression
Marked anti tumour effect in leukamia, hodgkin disease and non hodgkin lymphomas
Enhance appetite and sense of well being in end stage malignant disease
They are powerful immunosuppresant
Used to prevent organ transplant
rejection and in high doses to treat rejection episode
Facts about Ciclosporin
Potent immunosuppressant
Marked nephrotoxic
Used in organ and tissue transplant
Prevention of graft rejection following bone marrow, kidney, liver , pancreas, heart, lung and heart -lung transplant
What drug is used in the prophylaxis and treatment of graft-versus-hot disease
Ciclosporin
Ciclosporin should be prescribed by brand. True or false
True
Monitoring requirements for ciclosporin
Blood concentration
With systemic use- dermatological and physical examination ( for atopic dermatitis and psoriasis)
Liver function ( if given with NSAID)
Serum potassium
Blood lipids before and after 1month of treatment
Kidney function and blood pressure ( discontinue in htn that cannot be co trolled develop)
Contraindications of ciclosporin
Uncontrolled infection, Uncontrolled blood pressure and malignancy
List the two major electrolytes to monitor with ciclosporin
Serum k and Mg
Why monitor serum K while on ciclosporin
Risk of hyperkalaemia esp in renal dysfunction
Why monitor Magnesium in patients on ciclosporin
Causes hypomagnesaemia
Ciclosporin patients and carer advice
With systemic use, counsel pt on administration of different formulations
Avoid excessive exposure to UV light including sun light
Avoid use of UVB or PUVA in psoriasis and atopic dermatitis
Ocular use: may affect driving and skilled task ( increased risk of blurred vision)
RBC aphasia, bone marrow suppression ( neutro, thrombocytopenia)
Other Monitoring requirements (ciclosporin)
Monitor FBC weekly for first month , then monthly for first 3 months, then every 3 months for next year, use oral if IV is irritant
Drugs that causes bone marrow suppression
Azathioprine, ciclosporin methotrexate
MAC
Vincristine and bleomycin causes Bone marrow suppression true or false
False
Side effect of ciclosporin
Eye inflammation
Food interaction with ciclosporin
Pomelo juice is predicted to increase ciclosporin exposure and purple grape fruit is predicted to decrease exposure
Tacrolimus must be prescribed by brand . T/F
T
Tacrolimus causes greater neurotoxicity. True/false
True
Facts about Tacrolimus
Similar mode of action and ADR to ciclosporin
Cardiomyopathy reported
Bone marrow suppression
Disturbance of glucose metabolism (signs of hyperglycemia)
Causes hyperkalaemia
Monitoring requirements with Tacrolimus
Monitor liver and kidney function
Patient and carer advice for Tacrolimus
Avoid excess exposure to UV light including sunlight ( use wide spectrum SPF)
May affect performance of skilled task( eg driving)
Indication of Sirolimus
Licensed for renal transplantation
Prophylaxis of organ transplant rejection in kidney recipients
Which ethnicity may require higher doses of Sirolimus
Afro carribean
Monitoring with Sirolimus
Blood- sirolimus trough concentration
Patient and carer advice on sirolimus
Avoid excessive exposure to UV light
