Immune System + Malignant disease Flashcards
You are a trainee pharmacist who is attending an acute oncology service ward round. In listening to a discussion about a patient, you hear that the patient has metastatic bowel cancer. In cancer pathology, what does the term “metastasis” refer to?
A) The spread of cancer cells from the primary tumour to other parts of the body
B) The initial formation of a tumour
C) The process of cancer cell death
D) The differentiation of cancer cells
E) The encapsulation of a tumour
A
RATIONALE: METASTASES IS DEFINED AS THE SPREAD OF CANCER CELLS
FROM THE PRIMARY TUMOUR TO OTHER PARTS OF THE BODY. QUITE
OFTEN THE LOCATION OF METASTASES IS DEPENDENT ON THE NATURE OF
THE INITIAL TUMOUR. FOR EXAMPLE, BRAIN AND BONE METASTASES ARE
VERY COMMON FOR LUNG CANCERS. THE PROCESS OF CANCER CELL DEATH
IS APOPTOSIS. THE ENCAPSULATION OF A TUMOUR REFERS TO A TUMOUR
BEING RESTRICTED TO A SPECIFIC SITE, SURROUNDED BY TISSUE. THE
DIFFRENTIATION OF CANCER CELLS REFERS TO STAGING, IN WHICH
DIFFERENT CANCER CELLS ARE SET APART BASED ON SIZE, LOCATION AND
WHETHER THEY’VE METASTASISED OR NOT.
Which viral infection is a known risk factor for the development of cervical cancer?
A) Hepatitis C virus (HCV)
B) Human immunodeficiency virus (HIV)
C) Human papillomavirus (HPV)
D) Influenza
E) Varicella-zoster virus (VZV)
C
RATIONALE: HUMAN PAPILLOMAVIRUS (HPV), OR HPV IS A RISK FACTOR
FOR CERVICAL CANCERS. ABOUT 10% OF WOMEN WITH HPV INFECTION ON
THEIR CERVIX WILL DEVELOP LONG-LASTING HPV INFECTIONS THAT PUT
THEM AT RISK FOR CERVICAL CANCER. KNOWING THIS LINKS TO YOUR
KNOWLEDGE OF VACCINATION SCHEDULE. VARICELLA-ZOSTER VIRUS IS
ASSOCIATED WITH SHINGLES, INFLUENZA IS AN ACUTE INFECTION. HIV IS
OFTEN ASSOCIATED WITH OTHER CANCERS SUCH AS KAPOSI’S SARCOMA.
HEPATITIS C IS NOT ASSOCIATED WITH CERVICAL CANCER BUT IS OFTEN
ASSOCIATED WITH LIVER CANCER.
You are a ward pharmacist counselling a patient on their newly started methotrexate for rheumatoid arthritis. You explain that whilst taking methotrexate, they should also take folic acid. Both the methotrexate and folic acid are to be taken weekly, but not on the same day. The rationale for this is:
A) Methotrexate is an antifolate agent, so taking folic acid on the same day as methotrexate would increase its efficacy
B) Methotrexate is an antifolate agent, so taking folic acid on the same day as methotrexate would decrease its efficacy
C) Methotrexate is a folate agent, so taking folic acid on the same day as methotrexate would increase its efficacy
D) Methotrexate is a folate agent, so taking folic acid on the same day as methotrexate would decrease its efficacy
E) Methotrexate works independently of folic acid
B
RATIONALE: METHOTREXATE IS AN ANTIFOLATE AGENT AND ACTS AS AN
ANTAGONIST TO FOLIC ACID. PATIENTS WHO TAKE METHOTREXATE ARE
OFTEN CO-PRESCRIBED FOLIC ACID 5 MG ONCE A WEEK, BUT IT SHOULD
NOT BE TAKEN ON THE SAME DAY AS METHOTREXATE. CO-
ADMINISTRATION ON THE SAME DAY WOULD REDUCE THE EFFICACY OF
METHOTREXATE, AS FOLIC ACID SUPPLEMENTATION MIGHT PARTIALLY
COUNTERACT METHOTREXATE’S INTENDED MECHANISM OF ACTION BY
PROVIDING THE FOLATE THAT METHOTREXATE IS DESIGNED TO DEPLETE.
THIS IS SIMILAR TO HOW TRIMETHOPRIM, ANOTHER ANTIFOLATE, SHOULD
NOT BE COMBINED WITH FOLIC ACID AS IT WOULD DIMINISH ITS
ANTIMICROBIAL EFFECTIVENESS.
Which class of drugs is commonly used to prevent or treat nausea and vomiting associated with chemotherapy?
A) Antibiotics
B) Anticoagulants
C) Antidiabetics
D) Antiemetics
E) Antihypertensives
D
Chemotherapeutic agents are given over a range of routes of administration. Some of these routes of administration allow for more convenient treatment. Some medications must be given by specific routes of administration. Vinca alkaloids, such as vincristine, may only be given:
A) Intramuscularly
B) Intrathecally
C) Intravenously
D) Intravitreally
E) Subcutaneous
C
RATIONALE: VINCA ALKALOIDS ARE ONLY EVER TO BE GIVEN
INTRAVENOUSLY. GIVEN BY ANY OTHER ROUTE, SUCH AS
INTRATHECALLY, CAN LEAD TO PARALYSIS AND DEATH. THIS IS AN
MHRA ALERT.
Which of the following is not a monitoring requirement of ciclosporin?
A) Blood Lipids
B) Full Blood Count
C) Heart Rate
D) Renal Function
E) Serum Electrolytes
C
RATIONALE: HEART RATE IS NOT A MONITORING REQUIREMENT FOR
CICLOSPORIN. CONVERSELY, ALL OTHER OPTIONS LISTED, INCLUDING
BLOOD PRESSURE, AND CICLOSPORIN BLOOD CONCENTRATION IS
REQUIRED TO BE MONITORED.
A patient who is being treated for large B-cell lymphoma is urgently rushed into A&E with suspected tumour lysis syndrome. Out of the following electrolyte disturbances, which is not a characteristic sign of tumour lysis syndrome?
A) Hyperkalaemia
B) Hyperphosphatemia
C) Hyperuricaemia
D) Hypercalcaemia
E) Hypocalcaemia
D
RATIONALE: TUMOUR LYSIS SYNDROME INVOLVES LARGE AMOUNTS
OF TUMOUR CELLS LYSING, RELEASING THEIR CONTENTS INTO THE
BLOOD STREAM AT THE SAME TIME. IT IS OFTEN CHARACTERISED BY
HIGH POTASSIUM, PHOSPHATE AND URIC ACID. PHOSPHATE AND
CALCIUM ARE ANTAGONISTIC TO ONE ANOTHER; IF POTASSIUM IS
ELEVATED, CALCIUM WOULD BE LOW.
A patient with severe Ulcerative Colitis has been admitted to the gastroenterology ward that you’re looking after. Before the patient starts treatment, the gastro team perform some screening. The screening includes virology (HepB and HIV), as well as TPMT. Which of the following drugs should not be commenced in someone with absent TPMT activity?
A) Azathioprine
B) Infliximab
C) Mycophenolate
D) Ustekinumab
E) Vedolizumab
A
RATIONALE: TPMT STANDS FOR THIOPURINE METHYLTRANSFERASE,
AN ENZYME USED IN THE METABOLISM OF THIOPURINE LIKE DRUGS
SUCH AS AZATHIOPRINE AND MERCAPTOPURINE. A LACK OF THIS
ENZYME RESULTS IN A LACK OF METABOLISM. NONE OF THE OTHER
DRUGS LISTED CONTAIN THE THIOPURINE GROUP
Mr MT has come off methotrexate after taking the tablets for the past two years. He has been on methotrexate for T-GL leukaemia. He explains that he and his long-term partner are hoping to start a family but would like advice on when it would be safe to start trying for a child. Which of th following is the most appropriate to advise?
A) Methotrexate will have no affect on MR H’s ability to father a child
B) Methotrexate is excreted in the semen, and Mr. H should wait at least three months before trying to conceive
C) Mr MT should inform his partner to wait for at least two menstrual cycles before she tries to conceive a child
D) Mr MT should wait at least six months before trying to conceive
E) Mr MT is now off methotrexate, so there is no risk to a child if they fall pregnant now
B
RATIONALE: APART FROM DRUGS UNDER THE PREGNANCY
PREVENTION PROGRAMME, SUCH AS SODIUM VALPROATE AND
ISOTRETINOIN, THERE ARE OTHER DRUGS WHICH CAN HAVE AN
EFFECT ON CHILDREN, PARTICULARLY THOSE THAT ARE CYTOTOXIC.
A FOETUS REQUIRES FOLIC ACID IN ITS DEVELOPMENT, SO IT IS
CRITICAL THAT THE PATIENT IS ADVISED CORRECTLY. MANY DRUGS
REMAIN IN THE SYSTEM AFTER CESSATION OF TREATMENT. IN
CASES WITH COUPLES WHERE THE MALE PARTNER TAKES
METHOTREXATE, THE ADVICE IS TO USE CONTRACEPTION AND WAIT
AT LEAST THREE MONTHS AFTER STOPPING TREATMENT BEFORE
ATTEMPTING TO CONCEIVE
which of the following medications are not a hormone antagonist?
A) Anastrozole
B) Degarelix
C) Exemestane
D) Letrozole
E) Olaparib
E
RATIONALE: OLAPARIB IS AN EXAMPLE OF A PARP INHIBITOR. ALL OF
THE OTHER CHOICES ARE HORMONE RECEPTOR ANTAGONISTS.
Miss S comes to your community pharmacy wishing to speak to you. You are the community pharmacist in a local village and have gotten to know many of your regular patients. Miss S trusts your judgement and wants your advice on managing a sore throat. She explains that she’s been having a persistent sore throat for the past few weeks, has a bit of a temperature, and feels run down and wants to know what she can take to manage it. Her regular medications include regular paracetamol, calcium carbonate, colecalciferol, methotrexate and macrogol sachets. She does explain she’s been going to a few house parties recently, so thinks she may have picked something up from there. What would you advise?
A) Advise that she can use some paracetamol as and when required up to a maximum to four times a day
B) Advise that she can use some benzydamine hydrochloride spray to help her sore throat every 3 hours when required
C) Advise that the sore throat is likely viral in nature, and so will pass with self-care
D) Advise that the sore throat may be indicative of blood dyscrasias, she needs to seek help from her GP
E) Advise that the sore throat may be indicative of blood dyscrasias, she needs to attend A&E
E
RATIONALE: METHOTREXATE AS AN IMMUNOSUPPRESSANT IS OFTEN
RELATED TO BLOOD DYSCRASIAS, SUCH AS THROMBOCYTOPENIA;
SUCH ADVERSE EFFECTS CAN PRESENT IN THE FORM OF A SORE
THROAT. PARACETAMOL WOULD BE INAPPROPRIATE DUE TO ITS
PYRETIC MASKING PROPERTIES WHICH COULD MASK POTENTIAL
NEUTROPENIC SEPSIS. WHILST BENZYDAMINE HYDROCHLORIDE OR
DIFFLAM IS OFTEN USED FOR A SORE THROAT, AGAIN THIS WOULD
MASK SYMPTOMS OF A POTENTIAL BLODO DYSCRASIA. WHILST THE
SORE THROAT COULD BE VIRAL IN NATURE, AT THIS POINT, YOU DO
NOT HAVE ENOUGH INFORMATION TO CONFIDENTLY MAKE THAT
JUDGEMENT ON THE BACKGROUND OF HER METHOTREXATE USE
EITHER. A GP REFERRAL MAY BE APPROPRIATE, BUT MAY TAKE TOO
LONG TO ACTION.
Mr. B asks for some advice about some treatment for mouth ulcers. He explains that he has a sore throat and a fever. His current medication includes mesalazine, sertraline, and he has recently been on a course of antibiotics. Which of the following is the best course of action?
A) Advise him to use bonjela. Bonjela is licensed for use in mouth ulcers
B) Advise him to use chlorhexidine 0.2% mouthwash. Chlorhexidine is an antiseptic and disinfectant, and this will stop the ulcers from becoming infected
C)Advise him that his condition will improve without any need for treatment. The ulcers may be a delayed side effect of the antibiotics, which will resolve
D) Advise him to use hydrocortisone 2.5mg oromucosal tablets and wash his mouth with them
E) Advise him to see his GP as soon as possible
E
RATIONALE: MESALAZINE AS AN AMINOSALICYLATE CAN CAUSE
BLOOD DYSCRASIAS. PATIENTS RECEIVING AMINOSALICYLATES, AND
THEIR CARERS, SHOULD BE ADVISED TO REPORT ANY UNEXPLAINED
BLEEDING, BRUISING, PURPURA, SORE THROAT, FEVER OR MALAISE
THAT OCCURS DURING TREATMENT. ANY OTHER OPTION CHOSEN
WOULD EITHER MASK THE DYSCRASIAS, OR NOT TREAT IT.
According to CRM guidelines on the handling of cytotoxics, which of the following statements is not true?
A) Eyes should be protected
B) Only trained individuals should reconstitute cytotoxics
C) Pregnant staff should not handle cytotoxics
D) Provided that personnel are trained, reconstitution of drugs can be performed anywhere.
E) Use local procedures for dealing with spillages and safe disposal of waste material, including syringes, containers, and absorbent material
D
RATIONALE: USING CRM GUIDELINES, TRAINED PERSONNEL SHOULD
CARRY OUT DRUG RECONSTITUTION IN DESIGNATED PHARMACY
AREAS, RATHER THAN IN ANY AREA. CONSIDER THAT SOME DRUGS
ARE CYTOTOXIC, POWDERS HAVE THE POTENTIAL TO HARM OTHER
PEOPLE IN THE AREA IF EXPOSED
Mr. P comes to your community pharmacy and explains that he is going away to Greece on holiday. He had a kidney transplant seven years ago. You have known Mr P for many years now. He has come to collect a 2-month supply of his tacrolimus before he goes on holiday for 6 weeks. His flight is in two hours, and he doesn’t have much time to wait. When you check the patient’s PMR, his previous prescriptions were for Adoport, but his most recent prescription is for Prograf. What is the most appropriate action for you to take?
A) Supply Mr. P Adoport at the same dose that he has been given previously. The prescription is most likely a selection error on the prescribing system, and he has been stable on Adoport for years now
B) Supply Mr P Adoport at the same dose of the Prograf. The choice of brand is most likely a selection error on the prescribing system, but the dose may have been changed following a medical review
C) Supply Mr P Prograf as prescribed. The two brands are interchangeable
D) Call the prescriber to query the change. The brands are not interchangeable and switching brands generally requires careful supervision under a specialist
E) Supply Mr P. the Prograf as prescribed so that the patient does not miss their flight but contact the doctor as soon as possible to query the change
D
RATIONALE: SOME MEDICATIONS, PARTICULARLY
IMMUNOSUPPRESSANTS MUST BE PRESCRIBED BY BRAND, AS NOT
ALL BRANDS ARE BIOEQUIVALENT. THIS IS AN EXAMPLE OF A
SCENARIO WHERE YOU MAY WANT TO AVOID AN IMPATIENT, ANGRY
PATIENT, HOWEVER PATIENT SAFETY MUST ALWAYS BE PUT FIRST.
IT WOULD NOT BE WITHIN THE REMIT OF THE PHARMACIST IN THIS
SCENARIO TO CHANGE THE BRAND, AS DOING SO OULD LEAD TO
TOXICITY OR ORGAN REJECTION.
Which of the following is a common side effect of immunosuppressive medications?
A) Hyperglycaemia
B) Hypertension
C) Neutropenia
D) Hyperkalaemia
E) Hyperlipidaemia
C
A patient with CLL has presented to a day case ward to receive treatment for their chronic lymphocytic leukaemia. Due to the uncontrolled nature of her disease, her WCC comes back as 33 x109. Based on the information provided, what is the most appropriate action when supplying rituximab for this indication. Use the resource pack provided (https://www.medicines.org.uk/emc/product/793/smpc#about-medicine)
A) The dose can be given without any pre-medication
B) The dose must be given after 100mg intravenous methylprednisolone
C) The dose must be given after 100mg oral methylprednisolone
D) The dose must be given after 100mg intravenous prednisolone
E) The dose must be given after 100mg oral prednisolone
D
What is the primary function of the thymus in the immune system?
A) Antibody production
B) Filtration of blood
C) Platelet activation
D) Red blood cell production
E) T cell maturation
E
RATIONALE: THE THYMUS IS THE ORGAN PRIMARILY
RESPONSIBLE FOR THE PRODUCTION AND MATURATION OF
IMMUNE CELLS; INCLUDING SMALL LYMPHOCYTES THAT
PROTECT THE BODY AGAINST FOREIGN ANTIGENS.
Which of the following is not a side effect that patients on immunosuppressants must report?
A) Bleeding
B) Bruising
C) Gastrointestinal upset
D) Sore Throat
E) Temperature
C
RATIONALE: WHILST GASTROINTESTINAL UPSET IS A
COMMON SIDE EFFECT OF MANY IMMUNOSUPPRESSANTS, IT
IS NOT A SIDE EFFECT SPECIFIC TO THIS CLASS OF
MEDICATIONS THAT WOULD WARRANT REPORTING AS A RED
FLAG SYMPTOM IN THE SAME WAY THE OTHERS LISTED
WOULD.
Miss M has been on a regimen that includes lenalidomide for control of her haematological condition. She is now on her last cycle of treatment. In clinic, she explains to the haematology clinical nurse specialist that she and her boyfriend really want to try and have children. They’ve put it off due to her treatment, but now that she’s stopping treatment, she doesn’t want to waste any time. The clinical nurse specialist calls you, the pharmacist working in cancer services, and asks you when Miss M can start trying to conceive. What is the most appropriate thing to advise?
A) Advise that Miss M can start the day after she stops treatment. Lenalidomide has a short half-life of 4 hours, so after 5 half-lives, she’ll have cleared the drug
B) Advise that Miss M should wait at least 90 days before trying to conceive
C) Advise that Miss M should wait at least 4 weeks before trying to conceive
D) Advise that Miss M should wait at least 8 weeks before trying to conceive
E)Advise that Miss M will have to discuss this with the consultant in charge of her care, as this is a consultant decision
C
RATIONALE: THE TIME TAKEN BETWEEN CESSATION OF A DRUG AND
CONCEPTION IS DEPENDENT ON THE DRUG, NOT NECESSARILY HALF
LIFE. ADVISING ANY SOONER COULD LEAD TO BIRTH DEFECTS.
REFERRAL TO THE CONSULTANT IS INAPPROPRIATE ALSO, AS THIS IS
SOMETHING AS A PHARMACIST YOU SHOULD BE ABLE TO MANAGE.
Pembrolizumab is a drug that is used in the treatment of non-small cell lung cancer. In terms of its mechanism of action, pembrolizumab is an example of:
A) Cytotoxic chemotherapy
B) Hormone therapy
C) Immunotherapy
D) Non-cytotoxic chemotherapy
E) PARP Inhibitor
C
RATIONALE: IMMUNOTHERAPY IS OFTEN USED IN CONJUNCTION WITH
CYTOTOXIC CHEMOTHERAPY, RADIOTHERAPY, OR TARGETED THERAPIES
FOR SYNERGISTIC TREATMENT OF MALIGNANCY, BUT NOT ALL
THERAPIES ARE CLASSED AS CHEMOTHERAPY.
Mr A has just been started on ciclosporin. He is collecting his outpatient prescription following his clinic appointment. You are the responsible pharmacist in the outpatient pharmacy within the hospital. When counselling Mr A. he explains that the consultant said there are some foods which he cannot have, and some juices he cannot have – the latter upsets him as he likes a multitude of different juices. Which of the following options can Mr. A not have whilst on ciclosporin?
A) Apple Juice
B) Banana Juice
C) Cranberry Juice
D) Grapefruit Juice
E) Orange juice
D
RATIONALE: GRAPEFRUIT JUICE INHIBITS THE METABOLISM OF
CICLOSPORIN FOR A BRIEF PERIOD AFTER
ADMINISTRATION.APPLE JUICE AND ORANGE JUICE ARE OFTEN
RECOMMENDED TO AID WITH TOLERATING THE TASTE OF THE
FORMULATION. CRANBERRY JUICE INTERACTS WITH WARFARIN,
AND BANANA JUICE IS NOT RELEVANT HERE.
A patient was taking Capimune (ciclosporin) for many years following a kidney transplant. Unfortunately, due to supply issues, he is no longer able to obtain this specific brand. After a clinic review with his tertiary centre, the decision is made to switch him to Neoral, another brand of ciclosporin. Brand switching requires careful monitoring. Which of the following options is not a monitoring requirement when switching between different ciclosporin brands?
A) Blood pressure
B) Ciclosporin concentration
C) Serum creatine kinase
D) Serum creatinine
E) Transplant organ function
C
RATIONALE: SERUM CREATINE KINASE IS USEFUL IN THE
MONITORING OF STATINS, DAPTOMYCIN, OR IN CASES WHERE
THERE IS RISK OF MYOPATHY OR RHABDOMYOLYSIS. THIS IS
NOT RELEVANT IN THIS CLINICAL SCENARIO.
Which of the following drugs is not mildly emetogenic?
A) Carboplatin
B) Etoposide
C) Fluorouracil
D) Methotrexate
E) Vinblastine
A
RATIONALE: CARBOPLATIN IS MODERATELY EMETOGENIC.
ALL OF THE OTHER OPTIONS ARE MILDLY EMETOGENIC.
Mr B presents to your community pharmacy. You’ve known Mr B for many years. Unfortunately, he has developed a case of community acquired pneumonia, and requires antibiotics. He has a penicillin allergy, for which he develops a rash. His normal medications include tacrolimus. Which of the following is the most appropriate choice of antibiotic for his infection?
A) Cefalexin
B) Clarithromycin
C) Co-amoxiclav
D) Erythromycin
E) Levofloxacin
E
RATIONALE: THE PATIENT HAS A TRUE PENICILLIN ALLERGY, SO CO-
AMOXICLAV WOULD NOT BE APPROPRIATE DUE TO ITS CONTENTS OF
AMOXICILLIN AND CLAVULANIC ACID. CEFALEXIN HAS A
STRUCTURALLY SIMILAR BETA LACTAM TO PENICILLINS, AND IS NOT
INDICATED IN COMMUNITY ACQUIRED PNEUMONIA. CLARITHROMYCIN
AND ERYTHROMYCIN BOTH INTERACT WITH HIS TACROLIMUS.
