Immune system and malignant disease

Question 1

Why do we give folic acid and how often to patients on methotrexate?

Answer 1

To reduce the possibility of methotrexate toxicity (unlicensed)
Give weekly on different days

Question 2

Example of Antiproliferate Immunosuppresant

Answer 2

Azathioprine
Mycophenolate

Question 3

Indication of Azathioprine

Answer 3

IBD. RA, autoimmune condition, suppression of transplant rejection, severe refractory eczema

Question 4

Important interaction of Azathioprine

Answer 4

Increases the risk of haematological toxicity when given with allopurinol
Reduce the dose of Azathioprine to 1/4 when given with allopurinol

Question 5

Azathioprine is broken down into

Answer 5

MERCAPTOPURINE

Question 6

Side effect of Azathioprine

Answer 6

Bone marrow depression, increased risk of infection, leucopenia, thrombocytopenia, pancreatitis.
Nausea
Neutropenia and thrombocytopenia

Question 7

Side effect of Azathioprine may require drug withdrawal. True/false

Answer 7

True

Question 8

Side effect of Azathioprine that requires immediate withdrawal

Answer 8

Hypersensitivity rxn such as Dizziness, malaise, rash, N andV, fever

Question 9

All immuosupressant are teratogenic. True/false

Answer 9

True

Question 10

Azathioprine pre treatment screening

Answer 10

TPMT enzyme metabolises thiopurine drugs
AbsentTPMT activity- Don’t give thiopurine drugs
Reduced TPMT activity- treat under specialist care

Question 11

Risk of myelosuppression increases in patients with reduced TPMT activity on Azathioprine. True/false

Answer 11

True

Question 12

List examples of thiopurine

Answer 12

Tioguanine
Mercaptopurine
Azathioprine

Question 13

Patient and carer advice for Azathioprine

Answer 13

Report any signs of bone Marrow suppression such as inexplicable bruising or bleeding, infection

Question 14

Facts about Mycophenolate

Answer 14

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

Question 15

Caution with mycophenolate

Answer 15

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

Question 16

State what to do if recurrent infections develop when taking mycophenolate

Answer 16

Measure serum immunoglobulin levels
Consider bronchiectasis or pulmonary fibrosis if persistent respiratory symptoms eh cough and dyspnoea

Question 17

Conception and contraception with mycophenolate

Answer 17

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

Question 18

How.long should male patients and their partners use contraception while on mycophenolate

Answer 18

During tx and for 90days after discontinuation

Question 19

Patients and carer advice while on mycophenolate

Answer 19

Warn patients to report any signs of bone marrow suppression eg infections, bruising or bleeding
Female patients should be part of PPP

Question 20

Facts about corticosteroids in immunosuppression

Answer 20

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

Question 21

Facts about Ciclosporin

Answer 21

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

Question 22

What drug is used in the prophylaxis and treatment of graft-versus-hot disease

Answer 22

Ciclosporin

Question 23

Ciclosporin should be prescribed by brand. True or false

Answer 23

True

Question 23

Monitoring requirements for ciclosporin

Answer 23

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)

Question 23

Contraindications of ciclosporin

Answer 23

Uncontrolled infection, Uncontrolled blood pressure and malignancy

Question 24

List the two major electrolytes to monitor with ciclosporin

Answer 24

Serum k and Mg

Question 24

Why monitor serum K while on ciclosporin

Answer 24

Risk of hyperkalaemia esp in renal dysfunction

Question 25

Why monitor Magnesium in patients on ciclosporin

Answer 25

Causes hypomagnesaemia

Question 26

Ciclosporin patients and carer advice

Answer 26

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)

Question 27

Other Monitoring requirements (ciclosporin)

Answer 27

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

Question 28

Drugs that causes bone marrow suppression

Answer 28

Azathioprine, ciclosporin methotrexate MAC

Question 29

Vincristine and bleomycin causes Bone marrow suppression true or false

Answer 29

False

Question 30

Side effect of ciclosporin

Answer 30

Eye inflammation

Question 31

Food interaction with ciclosporin

Answer 31

Pomelo juice is predicted to increase ciclosporin exposure and purple grape fruit is predicted to decrease exposure

Question 32

Tacrolimus must be prescribed by brand . T/F

Answer 32

T

Question 33

Tacrolimus causes greater neurotoxicity. True/false

Answer 33

True

Question 34

Facts about Tacrolimus

Answer 34

Similar mode of action and ADR to ciclosporin Cardiomyopathy reported Bone marrow suppression Disturbance of glucose metabolism (signs of hyperglycemia) Causes hyperkalaemia

Question 35

Monitoring requirements with Tacrolimus

Answer 35

Monitor liver and kidney function

Question 36

Patient and carer advice for Tacrolimus

Answer 36

Avoid excess exposure to UV light including sunlight ( use wide spectrum SPF) May affect performance of skilled task( eg driving)

Question 37

Indication of Sirolimus

Answer 37

Licensed for renal transplantation Prophylaxis of organ transplant rejection in kidney recipients

Question 38

Which ethnicity may require higher doses of Sirolimus

Answer 38

Afro carribean

Question 39

Monitoring with Sirolimus

Answer 39

Blood- sirolimus trough concentration

Question 40

Patient and carer advice on sirolimus

Answer 40

Avoid excessive exposure to UV light