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Symptoms > Involuntary Weight Loss > Flashcards

Involuntary Weight Loss Flashcards

1
Q

Mr. M is a 35 YO male who comes in for evalulation of weight loss. He reports a loss of 35 lb in the last 6 mo. Vitals are normal. He is thin, with temporal wasting and bilateral enlarged cervical lymph nodes.

What are your top diagnoses?

What tests do you order?

A
  • Top Diagnoses: HIV, cancer
  • Tests
    • CBC & differential
    • Complete metabolic profile
    • TSH
    • HIV Ab
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2
Q

Normal CD4 T-cell count = _______

CD4 T-cell count <200 = ________

A

Normal CD4 T-cell count = 450-500

CD4 T-cell count <200 = risk for opportunistic infections (PCP)

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3
Q

For treating HIV:

How many drug classes?

How many drugs?

Why?

A
  • 3 or more drugs
  • > 2 drug classes
  • Stop viral replication
  • Prevent mutations that can lead to resistance
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4
Q

What factors should you consider when selecting the initial drug regimen to treat a patient’s HIV?

A
  • Viral resistance profile
  • Factors to enhance compliance
    • Dosing frequency, pill burden, combination products
    • Tolerable side effects
    • Cost
  • Other Rx: drug-drug interactions
  • Co-morbid conditions
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5
Q

What are some examples of drug combinations for treatment of HIV?

A
  • 2 NRTIs + integrase inhibitor (___-tegravir)
  • 2 NRTIs + PI (____-navir) + booster
  • 2 NRTIs + NNRTI
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6
Q

What are some examples of this drug combination?

2 NRTIs + integrase inhibitor

A

tenofovir + emtricitabine + raltegravir

tenofovir + emtricitabine + dolutegravir

abacavir + lamivudine + dolutegravir

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7
Q

What are some examples of this drug combination?

2 NRTIs + PI + booster

A

tenofovir + emtricitabine + darunavir + ritonavir

tenofovir + emtricitabine + atazanavir + ritonavir

abacavir + lamivudine + darunavir + ritonavir/cobicistat

tenofovir + emtricitabine + lopinavir + ritonavir

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8
Q

What are some examples of this drug combination?

2 NRTIs + NNRTI

A

tenofovir + emtricitabine + efavirenz

tenofovir + emtricitabine + rilpivirine

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9
Q

What is something you would like to know before prescribing abacavir?

A
  • HLA-B*5701 status
  • Associated w/ potentially fatal hypersensitivity rxns
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10
Q

What is something you would like to know before prescribing a protease inhibitor?

A
  • Diabetes
    • PI’s block GLUT4 glucose uptake & can decrease glucose sensing by ß-cells
  • Hyperlipidemia, CV disease
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11
Q

What is something you would like to know before prescribing ritonavir?

A

Ritonavir is a strong inhibitor of CYP3A

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12
Q

Which of the following may be of concern in patients with a history of psychiatric illness?

  • Maraviroc
  • Zidovudine
  • Efavirenz
  • Raltegravir
  • None of the above
A

Efavirenz

  • High incidence of CNS & psychiatric symptoms, possibly for suicide ideation
  • Strong in 1st month, decreases over time
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13
Q

What are the side effects of Maraviroc?

A

hepatic, cardiovascular

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14
Q

What are the side effects of Zidovudine?

A
  • Bone marrow suppression
  • Drug interactions: glucuronyltransferase
  • Myopathy
  • Lactic acidosis, hepatic steatosis
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15
Q

What are the side effects of Raltegravir?

A
  • Myopathy
  • CK elevations
  • Some hypersensitivities
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16
Q

Your patient Mr. M comes back after 2 years of HIV treatment with a 10 lb weight loss & difficulty swallowing. He has missed several of his last appointments. On exam, you see this:

What does he have?

A

Oral Candidiasis

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17
Q

What are each of these?

A
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18
Q

What is the most effective mechanism to prevent opportunistic infections in HIV patients?

A

Inhibit HIV replication

  • Keeps CD4 counts high enough to lessen chance of opportunistic infections
  • Low CD4 counts increase susceptibility to opportunistic infections including fungi
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19
Q

If your HIV patient comes into your office with oral candidiasis, what questions do you have for them? What tests would you like to order?

A

Have you been taking all of your HIV drugs daily?

HIV viral load & CD4 count

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20
Q

What is the most common initial treatment for oral Candida?

A
  • Fluconazole (pill, oral)
  • Clotrimazole (oral troche)
  • Nystatin (oral suspension)
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21
Q

What are some drug interactions to be concerned about when administering fluconazole?

A
  • Fluconazole & other -conazole anti-fungals work by inhibiting fungal P450s
  • They also inhibit human CYP3A & CYP2C9
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22
Q

______ do not have significant CYP interactions

A

NRTIs

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23
Q

_______ ________ are metabolized by CYP3A

A

Protease inhibitors are metabolized by CYP3A

-conazole antifungals can increase PI levels

24
Q

NNRTIs & maraviroc have __________ links

A

CYP3A

  • Maraviroc: CYP3A substrate
  • NNRTIs can inhibit & introduce CYP3A & other CYPs
25
Q

If your patient has Candida glabrata, what should you switch them to? (from fluconazole)

A
  • Oral
    • Itraconazole
    • Voriconazole
    • Posaconazole
  • IV
    • Caspofungin
    • Anidulafungin
    • Micafungin
    • Amphotericin B (if life-threatening)
26
Q

What do you need to consider if your HIV patient skipped some days of medication & developed oral candidiasis?

A

May have developed resistance secondary to his many missed doses

  • Check for mutations which preclude resistance to certain medications
  • Genotype
27
Q

A 55 YO otherwise healthy male has lost 20 lb in the last 2 mo. He has had an increase in urination (all day) & feels thirsty all day. He drinks 6-8 glasses of water everyday. He has mild nausea when eating heavy meals & mild tenderness on R calf after recent bike ride. He is noticably more pale than normal.

On exam he has unilateral edema & swelling of the R calf. Chemistry reveals Na 130, K 4.9, Glucose 360. On lower extremity ultrasound he has a +R DVT.

What is going on here?

A
  • Summary: Otherwise healthy & fit individual w/ weight loss & new diagnosis of diabetes & DVT
  • Loss of >10% of body weight = RED FLAG
  • Unilateral swelling & erythema = RED FLAG
  • Migratory thrombophlebitis = Trousseau syndrome
  • You’re thinking MALIGNANCY
28
Q

What is Trousseau syndrome?

*from First Aid*

A
  • Migratory thrombophlebitis
  • Redness & tenderness on palpation of extremities
  • Indication of gastric or pancreatic cancer
29
Q

Your patient experiences increasing band-like epigastric pain. A CT scan of the chest abdomen & pelvis revealed a large head of the pancrease mass encasing the SMA & 4 liver metastases (largest 3cm) were noted. Serum CA 19-9 was 6500.

What test will provide you with the most information?

A

Liver metastasis biopsy

30
Q

What is a type of pancreatic cancer associated with flushing & diarrhea?

A

Neuroendocrine tumor

*carcinoid syndrome*

31
Q

Migratory thrombophlebitis is most commonly seen in which two cancers?

A

gastric cancer & pancreatic cancer

32
Q

Which of the following are known risk factors for pancreatic cancer?

  • Lynch Syndrome
  • Diabetes Mellitus
  • Peutz Jeghers Syndrome
  • BRCA Hereditary breast cancer
  • All of the above
A

All of the above

33
Q

Clinical signs of pancreatic cancer include:

  • Virchow’s node
  • Sister Mary Joseph’s node
  • Trousseau’s sign
  • Jaundice
  • All of the above
A

All of the above

  • Virchow’s node
    • Involvement of L supraclavircular node by metastasis from stomach
  • Sister Mary Joseph’s node
    • Subcutaneous periumbilical metastasis
34
Q

Treatment administered after surgical resection for pancreatic cancer is called:

  • Adjuvant treatment
  • Neoadjuvant treatment
  • Definitive treatment
  • Palliative treatment
  • Alternative treatment
A

Adjuvant treatment

  • Adjuvant treatment
    • Surgical intervention meant to cure & prevent metastasis after the definitive treatment
  • Neoadjuvant treatment
    • Before the definitive treatment
  • Definitive treatment
    • Standard for type of cancer with intention of curing
  • Palliative treatment
    • Treatment in incurable
    • Focus on symptoms
  • Alternative treatment
    • Different treatment sought out by patients w/ incurable diseases
35
Q

A drop in CA 19-9 (is/is not) considered a marker for improved survival in pancreatic adenocarcinoma.

A

IS

36
Q

Your patient has Metastatic Pancreatic Adenocarcinoma. What are some options for treatment?

A
  • Proposed treatment: Folfirinox chemotherapy
    • Overall survival = 11.1 mo
  • Gemcitabine in combination w/ nab-paclitaxel is a reasonable alternative
    • Overall survival = 8.5 mo
37
Q

What are some risk factors for pancreatic adenocarcinoma?

*First Aid*

A
  • Tobacco use
  • Chronic pancreatitis (esp >20 YO)
  • Diabetes
  • Age >50 YO
  • Jewish & African American males
38
Q

How does pancreatic adenocarcinoma present?

*First Aid*

A
  • Abdominal pain radiating to back
  • Weight loss (due to malabsorption & anorexia)
  • Migratory thrombophlebitis (Trousseau)
  • Obstructive jaundice w/ palpable, non-tender gallbladder (Courvoisier sign)
39
Q

What are the drugs approved for pancreatic cancer by the National Cancer Institute? (7)

A
  • Paclitaxel (albumin-stabilized)
  • 5-fluorouracil
  • Erlotinib
  • Everolimus
  • Gemcitabine
  • Mitomycin C
  • Sunitinib
40
Q

What are some drug combinations used for pancreatic cancer?

A
  • Gemcitabine + cisplatin
  • Gemcitabine + oxaliplatin
  • Folfirinox
    • Leucovorin + 5-FU + irinotecan + oxaliplatin
  • OFF
    • Oxaliplatin + 5-FU + leucovorin
41
Q

A patient is being treated w/ a combination of drugs for pancreatic cancer. Her recent labs show these serum abnormalities:

  • Creatinine: 5.5 [0.5-1.2 mg/dL]
  • BUN: 45 [6-20 mg/dL]
  • Mg2+: 0.2 [1.5-2.0 mM]

Which of these drugs is most likely responsible?

  • Cisplatin
  • Gemcitabine
  • 5-FU
  • Erlotinib
  • Paclitaxel
A

Cisplatin

  • Well-recognized cause of renal damage
  • Hydration & diuresis decrease risk
  • Electrolyte abnormalities
42
Q

Which of these drugs has a low incidence of renal toxicity & which have lower renal effects but no Mg2+ effects?

  • Gemcitabine
  • 5-FU
  • Erlotinib
  • Paclitaxel
A
  • Low incidence of renal toxicity
    • Erlotinib, 5-FU
  • Lower incidence renal effects (_<_12%), but not magnesium effects
    • Gemcitabine, paclitaxel
43
Q

What are two reasons for giving leucovorin in anti-neoplastic therapy?

A
  • Rescue normal cells from methotrexate
  • Enhance the effectiveness of 5-FU
44
Q

As predicted from their mechanisms of action, which of the following drugs for pancreatic cancer primarily targets the S phase of the cell cycle?

  • Paclitaxel
  • Erlotinib
  • Cisplatin
  • Gemcitabine
  • 5-FU
A

Gemcitabine, 5-FU

45
Q

What is the mechanism of action of 5-FU?

A

S-phase targeting

  • Pyrimidine analog
  • FdUMP inhibits thymidylate synthase
46
Q

What is the mechanism of action of Gemcitabine?

A

S-phase targeting

  • Dilfuorocytidine analog
  • Gemcitabine tri-P competes for dCTP for DNA incorporation
  • Gemcitabine di-P inhibits ribonucleotide reductase
47
Q

What is the mechanism of action of Paclitaxel?

A
  • Late G2 (G2/M)
  • Enhances assembly & stability of MTs
48
Q

What is the mechanism of action of Cisplatin?

A
  • Cycle-specific phase-non-specific
  • Platinumb coordination complex
    • DNA cross-links
  • Inhibits thioredoxin reductase
49
Q

What is the mechanism of action of Erlotinib?

A
  • Cell cycle arrest (in G1)
  • Inhibits tyrosine kinase of EGFR, blocking growth promoting signal
50
Q

A patient being treated for pancreatic cancer develops peripheral neuropathy. Which of the following drugs are most likely to cause this adverse effect?

  • 5-FU
  • Paclitaxel
  • Cisplatin
  • Gemcitabine
  • Oxaliplatin
  • Irinotecan
A
  • Peripheral Neuropathy
    • Paclitaxel, cisplatin, oxaliplatin
  • 5-FU: rare
  • Gemcitabine: <10% (usually mild)
  • Irinotecan: <3%
51
Q

What is the advantage of albumin-stabilized paclitaxel nanoparticles vs. paclitaxel?

A
  • Paclitaxel
    • Highly hydrophobic
    • Traditionally given w/ a detergent (Cremaphor)
      • Severe hypersensitivity rxns
    • Poor drug distribution/penetration
  • Albumin-stabilized paclitaxel
    • No detergent needed
      • Avoids hypersensitivity rxns
    • Improved tissue/tumor penetration
      • Improved anti-tumor effects
52
Q

What is Irinotecan?

A
  • Topoisomerase inhibitor
  • Blocks re-ligation of DNA strand breaks (during replication)
    • S-phase
53
Q

What are the most common side effects of Irinotecan?

A
  • Myelosuppresion (98%, dose-limiting)
  • Alopecia (60%)
  • Nausea, diarrhea, vomiting, fever
54
Q

What is the mechanism of Protease Inhibitors in treatment of HIV?

*First Aid*

A

“-navir”

  • Assembly of virions depends on HIV-1 protease (pol gene), which cleaves the polypeptide products of HIV mRNA into their functional parts
  • Thus, PIs prevent maturation of new viruses
55
Q

What is the mechanism of NRTIs in the treatment of HIV?

A
  • Competitively inhibit nucleotide binding to reverse transcriptase & terminate the DNA chain (lack a 3’ OH group)
  • Tenofovir is a nucleotide; the others are nucleosides & need to be phosphorylated to be active
56
Q

What is the mechanism of NNRTIs in the treatment of HIV?

A
  • Bind to reverse transcriptase at site different from NRTIs
  • Do not require phosphorylation to be active or compete w/ nucleotides

Symptoms (17 decks)

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