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NAPLEX > Ischemic Heart Disease > Flashcards

Ischemic Heart Disease Flashcards

1
Q

Nitroglycerin Contraindications?

A

Use in combination with ricoguat or PDE-5 inhibitors

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2
Q

What are the 3 beta blockers used in HF?

A
  1. Carvedilol
  2. Metoprolol succinate
  3. Bisoprolol
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3
Q

What is the ointmetn dosing?

For nitro

A

dose BID 6 hours apart

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4
Q

How should effient be dispensed?

A

In the original container

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5
Q

Long acting nitrates need what?

A

need a 10-12 hour nitrate free period to decrease tolerance

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6
Q

Patho of Ischemic heart disease?

A

Imbalance of myocardial demand (workload) and supply (blood flow)

Supply often decreased by arethrosclerosis which is CAD reduced blood flow to the heart

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7
Q

Ranexa MOA

A

inhibits late phase Na current decrease intracellular Ca

decrease myocardial oxygen demand

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8
Q

Preferred agent for Prinzmetal Angina?

A

CCBs

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9
Q

The ABCDE treatment for SIHD?

A
  1. A: antiplat and antiangina: BB, CCBs, Nitrates
  2. B blood pressure and beta blockers
  3. Cholesterol statins and cigs
  4. D diet and DM
  5. Exercise and education
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10
Q

Warnings for Nitrates 3

A

Hypotension, HA, tachyphylaxis (decreased effectiveness and tolerance)

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11
Q

Cardiac enzymes are positive in what types of ACS MI?

Negative?

A

NSTEMI

STEMI

Negative in UA

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12
Q

Effient contraindications?

A

Hx of TIA or Stroke

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13
Q

Clopidogrel is a prodrug metabolized by?

A

CYP 2C19 check genotype for best use

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14
Q

Ranexa Notes

A

Had no effect on HR or BP

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15
Q

SEs of aspirin? 3

A

Dyspepsia

Heartburn

Nausea

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16
Q

Patients with an acute MI, STEMI or Non-STEMI should be?

A

Transported to a hospital with PCI capabilities

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17
Q

What CCBs are preferred when using in combination with BBs?

A

DHPs

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18
Q

What is recommended in all patients? IHD

A

nitroglycerin for immediate releif

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19
Q

Patch instructions for LA nitrates?

A

on 12-14 hours off for 10-12 rotate sites

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20
Q

What is the goal of antianginal treatment in IHD?

A

Decrease myocardial pxygen demand and increase supply

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21
Q

Vaccine rec for IHD patietns?

A

Flu and pneumococcal Prevnar and Pneumovax

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22
Q

When are long acting nitrates indicated?

A

When BBs are contraindicated or as add on

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23
Q

Benefit of CCBs in IHD?

A

Non-DHPs: reduce HR

DHPs: reduce SVR afterload

All CCBs increase myocardial oxygen supply increase blood flow to the coronary arteries

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24
Q

WHat 4 properties does Aspirin have?

A
  1. Antiplat
  2. Antipyretic
  3. analgesic
  4. Anti inflammatory
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25
Q

What is effient indicated for?

A

Pts with ACS who are managed with PCI

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26
Q

What do nitrates do?

A

Decrease preload and

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27
Q

If patient is going for urgent CABG what shouldnt they get?

A

p2y12 inhibitors

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28
Q

SEs of Nitrates?

A

HA, flushing, syncope

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29
Q

What are the 3 GPIIb/IIIa antagonists?

Who are these for? What should they be given with?

A
  1. Abciximab
  2. Eptibifibatide
  3. Tirofiban

Option for medical management Eptibi, Tirofiban or for PCI +/- stent (all agents)

If used for PCI must be given with heparin

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30
Q

A complete or partial block is seen in what type of ACS?

A

Partial block in UA

Complete block in STEMI

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31
Q

What is a rare and serious SE of clopidogrel?

A

TTP: pale skin, fever, weakness

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32
Q

What is the benefit of BBs fo IHD

A

Decrease HR

Decrease contractility

Decrease left ventricular wall tension

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33
Q

Contraindications for Aspirin?

A

Salicylate allergy, children and teenagers due to risk of reyes

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34
Q

Indication for ACE in ACS?

Time it should be received?

Important to note?

A

Should be started within first 24 hours and continued indefinetly

In all pts with EF < 40%, those with HTN, DM, or stable CKD

ORAL

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35
Q

What chronic therapy should be initiated in ACS patients?

A

High intensity statin

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36
Q

Drug Treatment of ACS?

A
  1. MONA
    1. Morphine
    2. Oxygen
    3. Nitro
    4. Aspirin
  2. GAP
    1. GPIIb/IIIa antagonists
    2. Anticoagulants
    3. P2Y12 inhibtors
  3. BA
    1. Beta blocker
    2. ACE inhibitor
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37
Q

Prinzmetal Angina

A

Unpredicable caused by vasopasms

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38
Q

Anticoagulant Therapy in ACS? 3

A

LMWH, UFH, Bivalrudin (preferred for STEMI)

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39
Q

What is Yasprala and who is it used for?

A

Aspirin for patients at risk of developing aspirin associated gastric ulcers

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40
Q

Bayer, Bufferin, Ecotrin

A

Aspirin

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41
Q

What other med should be avoided with Brillinta?

A

Ticagrelor

Doses of aspirine above 100 mg should be avoided

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42
Q

Ranexa warnings?

A

QT prolongation

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43
Q

Clopidogrel warnings?

A

Increase bleed risk avoid use with omeprazole (prilozec) or esomeprazole (nexium)

Increased risk of thrombosis when DC prematurely

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44
Q

What medications should not be given during ACS?

A

NSAIDs

Immediate release nifedipine increases risk of death

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45
Q

Who should get DAPT?

3 and how long should they be on it?

For IHD

A
  1. Bare metal stent: at least 1 month
  2. drug eluting stent: 6 months
  3. Post CABG: 12 months
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46
Q

What therapy is recommended for IHD patients?

A

Antiplatelet with aspirin or clopidogrel if allergy or both in select patients

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47
Q

ACS?

A

Acute chest pain

  • Not relieved by rest or nitro
  • These include UA, NSTEMI, STEMI
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48
Q

Clopidogrel MOA?

A

Prodrug that irreversibly binds to P2Y12 ADP mediated platelet activation and aggregation

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49
Q

Ranexa

Drug interactions and dosing limits

A

With CYP3A4 moderate inhibitors (Dilt and verapamil) limit dose to 500 mg BID

DONT USE WITH STRONG 3A4s

If using simvastatin limit dose to 20 mg/day

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50
Q

Effient generic?

A

Prasugrel

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51
Q

Renexa

A

Ranolazine

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52
Q

Maintenance dose for Brillinta?

Administration notes

A

90 mg PO BID for 1 year then 60 mg BID

Tablets can be crushed or mixed

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53
Q

How to know if someone has stable ischemic heart disease?

When does pain occur?

How is it relieved?

A

It is predictable, happens with acitivity or stress relieved by rest or nitroglycerin

usual underlying cause of CAD

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54
Q

BBs should be avoided in?

A

Prizmetal ANgina

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55
Q

How is nitroglycerin given during an acute coronary sydrome?

A

Use one dose every 5 minutes for up to 3 doses of improvement is not seen 5 minutes after the first dose call 911

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56
Q

What drugs increase risk of bleeding for P2Y12s? 4

A

Warfarin, NSAIDs

SSRIs and SNRIs

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57
Q

Diagnosis of IHD

What is performed and why?

A

Cardiac stress test to assess the likelihood of CAD

Lexiscan or regafenoson

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58
Q

Monoket

A

Isosorbide mononitrate

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59
Q

Beta blockers

What is the target dose?

A

Trick question! Titrate slow to a target HR od 55-60

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60
Q

Clopidogrel dosing and contraindication

A

75 mg

COntra; serious bleeding

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61
Q

Alcohol shoul dbe limited to?

A

1 drink per day

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62
Q

IHD patients should do what with their lifestyle?

A

Heart healthy

maintain BMI of 18.5- 24.9

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63
Q

All nitroglycerin contain products patient counseling

A

Dont use with sildenafil, tadalafil, avanafil, riociguat

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64
Q

Nitroglycerin Spray COunseling

A

Dont shake

spray on or under the tongue dont inhale

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65
Q

Ideally when should a PCI be performed?

A

Within 120 minutes of first medical contact

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66
Q

Ranolazine

Counseling

A

Not for chest pain when it occurs

can cause QT prolongation

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67
Q

MOA of Aspirin?

A

Irreversibly binds to COX 1 and 2

Which decreases prostaglandin and thromboxane A2 production

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68
Q

Nexium and Prilozec should not be used with what?

A

Plavix

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69
Q

What is first line therapy for antiangina in IHD?

A

Beta blockers

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70
Q

Brillinta

A

Ticagrelor

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71
Q

3 recs for IHD patients?

A

BB, CCBs all, or long acting nitrates

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72
Q

What are the preferred aspirin formulations?

A

Non-enteric chewable formulations

If not available shew enteric coating

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73
Q

Ranexa Contraindications? 2

A

Liver cirrhosis

CYP3A4 inhibitors or inducers 3A4

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74
Q

What type of CCBs are effective?

A

Slow release and long acting

short acting shouldnt be used: Nifedipine IR

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75
Q

What GIIb/IIIa antagonist is not recommneded for medical managment?

A

Abciximan Reopro

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76
Q

Integrillin?

A

Eptifibatide

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77
Q

COntraindications for GIIb/IIa? 5

A
  1. Thrombocytopenia plats<100,000
  2. Severe uncontrolled HTN
  3. Active bleed
  4. Recent surgery or trauma 4 wks tirofiban, 6 weeks others
  5. Hx of stroke within the past two years for Reopro
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78
Q

Contraindications for Abciximab? 4

A
  1. GI bleed in past 6 wks
  2. Increased prothrombin time
  3. Hypersens to murine proteins
  4. Intracranial neoplasm, aneurysm
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79
Q

Integrillin contra

A

Eptifibatide

Dependency on dialysis

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80
Q

3 SEs of GIIBs/IIas

A
  1. Thrombocytopenia (ezpecially abcix)
  2. Bleeding
  3. Hypotension
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81
Q

Administration note for GIIb/IIas

A

Abciximab must be filtered

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82
Q

What are fibrinolytics used for?

A

Only used for STEMI

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83
Q

PCI timing preferred 2 time frames

A
  1. 90 minutes door to needle
  2. 120 from first medical contact
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84
Q

If it is not possible to perform PCI within 120 minutes what should be done?

A

Give fibrinolytic

Given within 30 minutes door to needle

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85
Q

Cathflo activase?

A

Used to restore function of potentially clotted central lines

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86
Q

Activase?

A

Alteplase

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87
Q

Activase dosing?

A

>67 kgs 100 mg over 1.5 hours

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88
Q

What are the two fibrinolytics?

A

Activase: Alteplase

Tenecteplase: TNKase

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89
Q

SEs of fibrinolytics?

A

Bleeding including ICH, hypotension

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90
Q

What 3 things should be monitored with fibrinolytics?

A

Hgb, Hct, s/sx bleeding

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91
Q

Protease activated receptor 1 antagonist? 1

Warnings 1

SEs 2

A

Varapaxar

Do not use in severe liver impairment

SEs: Anemia, Bleeding

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92
Q

Vorapaxar DIs?

A

Substrate of 3A4 and P-gP

Dont use with strong 3A4s

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93
Q

Secondary prevention in ACS

7 drugs

A
  1. Aspirin
  2. P2Y12s
  3. Nitro
  4. BBs
  5. ACE
  6. Aldosterone antagonists
  7. Statin
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94
Q

Secondary prevention after ACS:

Aspirin and P2Y12 notes

A
  1. Aspirin 81 mg forever
  2. Medical therapy pt: Ticagrelor or Clopdogrel with ASA for 1 year
  3. PCI treated DAPT
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95
Q

Secondary ACS prevention

Nitro and BBs timing

A
  1. Nitro indef with linguakl
  2. BBs: 3 years indef if HF pt or if needed for HTN management
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96
Q

Secondary ACS prevention ACE

Aldosterone antagonist

A
  1. Indef if EF < 40%, HTN, CKD, or DM, consider for all patients
  2. Aldosterone antagonist: Indef if EF<=40% and either symptomatic HF or DM receiving target doses of ACE and BB
  3. Contraindications: sig renal imparimetn SCr>2.5 in men, 2 for women or hyperkalemia K>5
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97
Q

Statin therapy ACS secondary prev

A
  1. <= 75 high intensigty
  2. > 75 mod
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98
Q

Pts with Chronic pain and ACS what is the DOC?

A

Naproxen lowest CV risk

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99
Q

If patient has to be on Warfarin and has ACS?

A

Lower warfarin INR goal if on triple therapy 2-2.5 nd for the shortest possible time

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100
Q

What is rec’d for ACS patients if they are getting triple anticoag?

A

PPIs if they have a hx of GI bleed while taking triple therapy

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101
Q

What is a cardioembolic stroke?

A

Embolus forms in the heart and travels to the nrain

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102
Q

SIgns and Symptoms of Stroke

A
  1. Face: one sided droop
  2. A Arms one drops
  3. S: slurred speech
  4. T: Time call 911 fast
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103
Q

What do you need to quickly indentify when lookling ar a stroke?

A

Ichemic versus hemorrhagic

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104
Q

What is performed to find what stroke is there?

A

Brain imaging CT scan

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105
Q

What is the immediate goal during a stroke?

A

Restore blood flow

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106
Q

Ischemic Stroke management?

What Agent is used?

What needs to be done?

A
  1. Alteplase (tPA), only fibrinolytic agent used for acute ischemic stroke
  2. Once a clot is confirmed use this
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107
Q

What criteria need to be met for alteplase use?

A
  1. Can be given 3 hours from symptom onset FDA approval
  2. Can be given within 4.5 hours in select patients
  3. It can be administered 60 minutes from hospital arrival door to needle
  4. BP is < 185/110: if this is the only contraindication then BP should be safely lowered and then admin
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108
Q

Activase dosing in ACS, and Stroke

Add pulmonary embolism when there

A
  1. ACS: If > 67 kg 100 mg over 1.5 hours
  2. Stroke 0.9 mg/kg max 90 mg
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109
Q

Absolute contraindications for Alteplase per package insert? 5

A
  1. Active bleed
  2. Recent within the past 3 months serious head injury
  3. Intracranial conditions that can increase bleed
  4. Intracranial or intraspinal surgery
  5. Severe uncontrolled BP > 185/110
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110
Q

Additional exclusion criteria for alteplase? 5

A
  1. Stroke within the past 3 months
  2. Previous ICH INR>1.7, aPTT > 40 plat <100,000
  3. Got Tx with LMWH within past 24 hours
  4. Use of Direct thrombin or direct factor Xa inhibitors with elevated anticoag tests or use within 48 hours
  5. BG < 50
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111
Q

Alteplase warnings? 2

A
  1. Major bleed ICH
  2. Angioedema
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112
Q

Alteplase notes?

A

Keep BP <180/105 for at least the first 24 hours after tx

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113
Q

All treatments for Stroke? 5

A
  1. Initial Alteplase
  2. Aspirin
  3. HTN management
  4. Hyperglycemia management
  5. DVT prevention
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114
Q

What dose and when should aspirin be given in stroke?

A
  1. 162-325 given 24-48 hours after stroke onset, dont give within 24 hours or Alteplase
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115
Q

HTN Managment in Stroke 3 rec drugs and BP target

A
  1. IV Labetalol, nicardipine, or clevedipine
  2. Lower to Bp <185/110 when alteplase is used maintain <180/105
  3. If they dont get alteplase may only need to treat in severe HTN BP>=220/120
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116
Q

Safe BP reduction?

A

15% in first 24 hours

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117
Q

Hyperglycemic managment in stroke?

A

keep BG in 140-180 range

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118
Q

DVT prevention is stroke? 2 things

A
  1. Compression socks pneumatic compression device
  2. If UFH or LMWH is used cannot be start until 24 hours after alteplase
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119
Q

Risk factors for stroke? 3

A
  1. HTN: Most important
  2. A. Fib
  3. Age >=55
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120
Q

Treating HTN in stroke?

2 drugs

A
  1. ACE
  2. HCTZ
  3. These have most evidence BP goal less than 130/80
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121
Q

A fib treatment in stroke

A
  1. Cardioembolic stroke due to a fib requires anticoag
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122
Q

Life style changes in Stroke? 2 bullets

A
  1. Sodium restriction < 2.4 grams/day or 1.5 for more BP reduction, mediterianian diet
  2. Wt reduction BMI goal 18.5-24.9 , waist in women < 35 inches, men < 40
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123
Q

What treatment is recommended in patients with noncardioembolic stroke or TIA?

A

Antiplatelet not anticoag

Antiplat reduces the risk of recurrence

Aspirin or aspirin + ER dipyridamole or clopidogrel

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124
Q

When should Plavix be used alone?

A

If pt has ASA allergy

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125
Q

When should combination ASA and Clopidogrel be intitiated and continued in STROKE?

A

within 24 hours and continued for at leat 21 days

Combo should not be used long term fro stroke or TIA due to increased hemorrhage risk

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126
Q

Dipyridamole MOA?

A

Inhibits the uptake of adenosine increases cAMP levels which inhibits plat ag

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127
Q

Aggrenox?

A

Dipyridamole

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128
Q

Warnings for Dipyridamole? SE?

A

Hypotension

SE: HA

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129
Q

Intracerebral Hemorrhage

Prevention treatments 2

A

Potentially reverse anticoag

and treat seizures when they happen not prophylaxticaly

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130
Q

What is the main treatment for ICH and what does it do?

A

Mannitol produces an osmotic diuresis, inhibits the tubular reabsorption of water and electrolytes, increases urinary output

BOTTOM LINE: Reduces intracranial pressure by withdrawing water from the brain

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131
Q

How is mannitol given for ICH?

A

IV

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132
Q

Mannitol Contraindications and Notes

A

Severe renal disease

Notes: Maintain serum osmolality <300-320 mOsm/kg

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133
Q

How does an acute subarachnoid hemorrhage present?

A

With a severe HA

Commonly cause by aneursym

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134
Q

What can occur in a subarachnoid hemmorhage and when?

A

Cerebral artery vasospasm

can happen 3-21 days after bleed

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135
Q

What is used to prevent cerebral vasospasms in SAH?

A

Oral Nimedipine

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136
Q

Nimedipine MOA?

A

DHP CCB: more selective for cerebral arteries

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137
Q

Boxed warning for nimodipine?

A
  1. NOT TO BE GIVEN IV death and threatening events have occured
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138
Q

Nimodipine DI?

A

Hypotension when used with CYP3A4s

  • Avoid CYP3A4 inhibitors: clarithromycin, PIs, azoles
  • Avoid grapefruit juice
  • Avoid CYP inducers: rifampin, carbamazepine, phenytoin, at johns: can decrease levels
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139
Q

Nimodipine SE?

A

Hypotension

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140
Q

Nimodipine notes?

A

If contents cannot be swallowed the capsule can be withdrawn with a parenteral syringe and then transfered to oral syringe

Label syringe for ORAL USE ONLY

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141
Q

Bleomycin Max dose

And what toxicity?

A

Lifetime cumulative 400 units

Pulmonary Toxicity

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142
Q

What 4 drugs have maximum dosing recommendations due to toxicities?

A

Bleomycin, Doxorubicin, Cisplatin, VIncristine

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143
Q

Doxorubicin Maximum dose and why?

A

Lifetime cumulative: 450-550 mg/m2

Cardiotoxicity

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144
Q

Cisplatin maximum dose and why?

A

Dose per cycle: not to exceed 100 mg/m2

Nephrotoxicity

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145
Q

Vincristine Maximum dose and why?

A

Single dose capped at 2 mg

Neuropathy

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146
Q

What drugs cause myelosuppression?

3

A

Almost all cause myelosuppression except Asparginase, bleomycin, vincristine

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147
Q

How should myelosuppression be treated in chemotherapy patients?

A

If neutropenic give Colony stimulating factor

Anemia: RBC transfusion

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148
Q

Chemo drugs that cause N/V 3 main

A
  1. Cisplatin
  2. Cyclophosphamide
  3. ifosfamide
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149
Q

How is nausea and vomitting treated in chemo therapy patietns? 6

A
  1. Neurokinin-1 receptor antagonists (NKI-RA)
  2. Serotonin 3 receptor antagonists (5HT3-RA
  3. Dexamethasone
  4. Metoclopramide
  5. Prochlorperazine
  6. IV/PO fluid and hyfration
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150
Q

5 chemo drugs that cause Mucositis?

A
  1. Fluorouracil
  2. Capecitabine
  3. Irinotecan
  4. Methotrexate
  5. And many TKIs including the nibs
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151
Q

How is mucositis treated in chemo therapy patients?

A

Symptomatic tx , local anesthtics

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152
Q

4 chemo drugs that cause diarrhea?

A
  1. Fluorouracil
  2. Capectabine
  3. Irinotecan
  4. and many TKIs
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153
Q

How is Diarrhea treated in chemo therapy patients?

A
  1. IV/PO fluid hydration, antimotiliy agents (loperamide)
  2. Irinotecan: atropine for early onset
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154
Q

Main drug that causes consiptation in chemo

A
  1. Vincristine
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155
Q

How to treat constipation in chemo?

A

Stimulant laxatives

polyethylene glycol

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156
Q

Xerostomia?

A

Dry mouth

Artificial saliva substitutes caused by radiation

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157
Q

Cardiotoxicity In Chemo

Cardiomyopathy specifically 1

A
  • Anthracyclines
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158
Q

Cardiotoxicity in chemo

QT prolongation? 2

A
  1. Arsenic trioxide
  2. TKIs, end in nib
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159
Q

How to treat cardiomyopathy in chemo patients?

A

Do not exceed cumulative dose of doxorubicin 450-550 mg/m2

and dexrazoxane can be given prophylactically

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160
Q

How to treat QT prolongation in cancer patient?

A

Maintain electrolyte balance consider holding therapy if QT interval is > 500 msec

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161
Q

4 chemo drugs that can cause pulmonary fibrosis

A
  1. Bleomycin
  2. Busulfran
  3. Carmustine
  4. Lomustine
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162
Q

Chemo drugs that cause hepatotox? 1 class?

A
  1. Antiandrogens
    1. Bicalutamide
    2. Flutamide
    3. Nilutamide
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163
Q

2 chemo drugs that cause Nephrotoxicity

A
  1. Cisplatin
  2. MTX
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164
Q

What can be given to treat nephro toxicity in chemo patients?

A
  1. Amifostine (ethyol) can be given prophylactically with cisplatin
  2. Ensure hydration
  3. DONT EXCEED MAX CISPLATIN DOSE OF 100 MG/m2/cycle
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165
Q

Two drugs in chemo that can cause hemorrhagic cystitis

A

Ifosfamide all doses

Cyclophosphamide higher doses > 1 g/m2

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166
Q

What can be given for hemorrhagic cystitis in chemo?

A
  1. Mesna (Mesnes) is ALWAYS given with ifosfamide and sometime cyclophos
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167
Q

3 classes of chemo drugs that cause peripheral sensory neuropathy

A
  1. Vinca alkaloids: Vincristine, vinblastine, vinorelibine
  2. Platinums: cisplatin, oxaloplatin
  3. Taxanes: Paclitaxel, docetaxel, cabazitaxel
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168
Q

Ways to reduce peripheral sensory neuropathy with vincristine?

A

limiting the dose to 2mg per wk

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169
Q

What does oxaliplatin cause?

A

Acute cold mediated sensory neuropathy avoid cold and cold drinks

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170
Q

Bortezomib SE treatmetn

A

SC admin is assoiciated with less peripheral neuropathy than IV

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171
Q

Chemo drugs that have thromboembolic risk? 2 classes

A

Aromatase inhibitors (anastrazole, letrozole)

SERMs (Tamoxifen)

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172
Q

What is amifostine (ethyol) for?

A

Given with cisplatin to prevent nephrotoxicity

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173
Q

What is Dexrazoxane used for?

A

With doxorubicin for cardiomyopathy prophylaxis

THis is Zinecard

Totect is used for extravacation

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174
Q

What is leucovorin or levoluecovorin (Fusilev) used for?

A
  1. Used with fluorouracil to enhance efficacy
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175
Q

What is Uridine triacetate used for? 2 things

A

Flourouracil and Capecitabine

As an antidote give within 96 hours

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176
Q

What is mesna used for?

A

Used with ifosfamide always to prevent hemmorhagic cycstis

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177
Q

What is atropine and loperamide used for>

A

Atropine: early onset diarrhea for Irinotecan

Loperamide: for delayed

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178
Q

Glucarpidase and Leucovorin or levoleucovorin used for?

A

given after methotrexate to prevent myelosuppresion and as a mucositis antidote

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179
Q

What hydration steps can you take with these drugs to reduce renal damage?

A

Mesna with Ifosfamide

Amifostene for cisplatin

When it damages the bladder and kidneys get it out with hypertonic solutions, these increase urine output and incluse mannitol and hypertonic saline

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180
Q

When are WBCs the lowest during chemo?

A

7-14 days

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181
Q

When do WBCs recover after treatment?

A

3-4 wks after

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182
Q

IOf someone has a low neutrophil count what can happen?

A

They are at increased risk of infection

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183
Q

Nuetropenia is classifies as an ANC of?

A

<1000 cells/mm3

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184
Q

What is severe neutropenia classified as?

A

ANC < 500 cells/mm3

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185
Q

What is used for the prevention of febrile neutropenia?

A

Filgrastim and Pegfilgrastim

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186
Q

Neupagen or Zarxio?

A

Filstastim G-CSF

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187
Q

Granix

A

Tbo-filgrastim

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188
Q

How is Neupagen, zarxio dosed?

A

Daily

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189
Q

Neulasta?

A

Pegfilgrastim

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190
Q

SEs for Filgrastim, pegfilgrastim and tbo-filgrastim?

A

Bone pain

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191
Q

Sargramostim SEs? 5

A

Fever, bone pain, arthralgias, myalgias, rash

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192
Q

How is Neulasta dosed?

A

Pegfilgrastim

Once per cycle

Pegylated filgrastim is longer acting and dosed less frequintly

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193
Q

How are CSFs stored?

A

Store in fridge protect vials from light

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194
Q

When should CSF be administered?

A

No sooner than 24 hours after chemo

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195
Q

What should pts report if on CSF?

A

Signs of enlarged spleen left upper ab pain

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196
Q

What is the potential only sign for neutropenia?

A

Fever can sometimes be the only sign of infection

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197
Q

How is febrile neutropenia defined?

What should be done?

A

Single oral temp of >38.3 or 101

ANC < 500

Oral temp >38 for greater than 1 hour

If the ANC is expected to drop below 500

EXTREMELY IMPORTANT TO GIVE EMPIRIC ABX

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198
Q

What infection type poses the highest sepsis risk in febrile neutropenia?

A

Gram negative

Inclusing Pseudomonas

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199
Q

Patients ANC is expected to drop below 500 for <= 7 days and has no comorbidities

What 3 Abx sets should be used?

A
  1. Anti-pseudomonal
    1. Cipro + amox/clav
    2. Or Cipro +/- clinda or
    3. Levofloxacin
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200
Q

Patietns ANC is expected to be < 500 for longer than 7 days and has comorbidities evidence of renal impairment CrCl<30 or LFTs > 5 x ULN

What 5 Abx are recommneded?

A

iv Antipseudomonas

  1. Cefepime or
  2. Ceftaz or
  3. Meropenem or
  4. Imepenem + cilstatin or
  5. Pip/tazo
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201
Q

What is not recommended in Chemo patients when you are trying to cure them and they have anemia?

A

ESAs they can increase tumor progression

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202
Q

What are the 4 criteria that need to be met if you are trying to use ESA in a cancer patient?

A
  1. Use ESA only in non myeloid malignancies where anemia is directly caused by the chemo
  2. If you use ESA you must have at least 2 more months of chemo
  3. Initiate ESA when Hgb is < 10
  4. Use the lowest dose needed to avoid the need for RBC infusions

Assess TBIC and TSAT to see if iron needs to be replaced because it will not work without it

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203
Q

When are platelet transfusions indicated in cancer patients or whenever?

A

WHen platelets are below 10,000 or 20,000 if active bleed

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204
Q

What are the 5 risk factors for chemotherapy induced Nausea and vomiting?

A
  1. Female
  2. < 50
  3. dehydrated
  4. Hx of motion sickness
  5. Hx of N/V with prior regimens
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205
Q

When should antiemetics be administered in CINV?

A

30 minutes before chemo

and provide take home meds

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206
Q

Acute N/V onset?

A

Within 24 hours after chemo

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207
Q

What is delayed nausea and vomiting onset?

A

1 to 7 days after

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208
Q

What is anticapatory N/V related to chemo therapy?

A

Before chemo

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209
Q

What is the treatment for acute N/V with chemo?

A

5HT3-RA

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210
Q

Treatment for delayed N/V associated with chemo? 3

A

1 to 7 days

NK1 receptor antagonists, corticosteroids, palonosetron (only 5HT-RA indicated for delayed)

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211
Q

Treatment of anticipatory N/V associated with chemo?

A

Benzos

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212
Q

What drug has very high chemo emetegenic risk?

A

Cisplatin

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213
Q

What drug is a combo NK1 /5HT3-RA?

A

Netupitant/palonasetron

Akynzeo

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214
Q

What NK1 is PO?

A

Arepitant

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215
Q

What NK1 is IV?

A

Fosaprepitant

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216
Q

What do NK1 end in?

A

Pitant

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217
Q

What do 5Ht3 RAs end in?

A

Setron

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218
Q

What are two other possible drugs for CINV?

A

Olanzapine

Dexamethasone

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219
Q

What drugs should a patient be put on if they are on a high emetic risk chemo regimen?

A

3 drugs

  1. NK1+5HT+Dexamethasone
  2. Netupitant/palonestron (Akynzeo) + dexamethasone
  3. Olanzapine + palonosetron + dexamethasone
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220
Q

What drug is included in all high or moderate emetic risk chemo regimens?

A

Dexamethasone

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221
Q

What drugs are commonly used for breakthrough CINV?

A

5HT3s, dopamine antagonists, cannabinoids

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222
Q

What do NK1s do?

A

Substance P/ neurokinin-1 receptor antagonists block these which augments the antiemetic activity of 5-HT3RA reeptor antagonists and corticosteroids

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223
Q

Emend?

A

Arepitant Oral

Fosarepitant injection

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224
Q

Contraindications to the Emends?

A

do not use with pimozide or cisopride: these are 3A4 substrates

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225
Q

What 3 NK1s are 3A4 inhibtiors and what should be doen?

A

Both emends and netupitant

Doses of dexamethasone should be decreased when used together

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226
Q

When are 5HT3s given?

A

1 day prior to chemo

Granisetron transdermal patch should be given prior to day 1

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227
Q

Zofran or Zuplenz film

A

Ondansetron

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228
Q

Sancuso?

A

pATCH FORMULATION OF GRANISETRON

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229
Q

Anzemet

A

Dolasetron

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230
Q

Aloxi

A

Palonosetron

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231
Q

Contraindication for 5HT3 RAs

A

Dont use with apomorphine (Apokyn) due to severe HTN and loss of consciousness

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232
Q

2 warnings for 5HT3s?

A

QT prolongation: dose dep more common with IV

Serotonin syndrome when given with other serotenergic agents

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233
Q

2 main SEs of 5HT3s?

A

HA, and constipation

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234
Q

What 5HT3 is not indicated for CINV and why?

A

Anzemet: IV Dolasetron: increase risk of QT prolongation

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235
Q

What 5HT3s are available both IV and PO?

A

All

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236
Q

Decadron

A

Dexamethasone

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237
Q

2 SEs of Dexamethasone?

A

Fluid retention and insomnia

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238
Q

3 dopamine receptor antagonists that are used in CINV?

A

Prochloperazine

Promethazine

Meclopramide

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239
Q

Compazine

A

Prochloperazine

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240
Q

Reglan

A

Meclopramide

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241
Q

Phenergen

A

Promethazine

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242
Q

Boxed warnings for Pherngen? 2

A

Dont give to kids < 2

Dont give intra-arterial or SC due to extravacation

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243
Q

Reglan black box?

A

Tardive dyskinesia that can be irreversible

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244
Q

Droperidol is what?

A

Dopamine antagonist

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245
Q

Droperidol Black box?

A

QT prolongation

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246
Q

What 4 key SEs of Dopamine receptor antagonists?

A
  1. Sedation
  2. Lethargy
  3. Decrease seizure threshold
  4. Actue EPS (common in children antidote is diphenhydramine or beztropine)
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247
Q

What dopamine antagonist is not used in CINV and why>

A

Droperidol due to high QT risk

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248
Q

Marinol?

A

Dranabinol

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249
Q

How is merinal stored?

A

Refridgerate

250
Q

Cesamet

251
Q

SEs of cannabinoids? 3

A

Somnolence, euphoria, increased appetite

252
Q

ODT ondansetron counseling?

A

With dry hand peal back dont push out of foil

253
Q

Chemo Induced Diarrhea patinet counseling?

A

Loperamide or diphenoxylate + atropine might be given to you

254
Q

What is the max dose of loperamide? Chemo Diarrhea

A

Max is usually 16 but can be increased to 24 in these patients

255
Q

What 3 chemo drugs commonly cause diarrhea? When does it happen?

A

Irinotecan

Capecitabine

Fluorouracil

Usually several days after

256
Q

Irinotecan and diarrhea

A

can cause early onset diarrhea due to cholnergic excess symptoms such as ab cramp, rhinitis, lacrimation and salivation

Early onset is treated with atropine

257
Q

Oral mucositis counseling

A

Many drugs that cause Chemo diarrhia cause mucositis

258
Q

What 4 drugs are used for Oral complications of Chemo?

A
  1. Mucosal barrier gel pray
  2. Lidocaine 2% topical solution
  3. Artificial saliva substitute (Xerostomia)
  4. Pilocarpine (Xerostomia)
259
Q

Salagen?

A

Pilocarpine

260
Q

Lido cain boxed warning?

A

Avoid in patients < 3

261
Q

Hand foot syndrome is also known as?

A

Palmar-plantar erythrodysethesia

262
Q

Hand foot syndrome occurs most frequently with what 4 chemo drugs?

A
  1. Fluorouracil
  2. Capecitabine
  3. Cytarabine
  4. Liposomal Doxorubicin
263
Q

What electrolyte disturbance is often seen in cancer?

A

Hypercalcemia of Malignancy

264
Q

What should all cancer patients be treated with when on chemo therapy

A

Proper hydration is key and hypercalcemia risk is high

give fluids, mannitol, and hypertonic

265
Q

What are the 4 treatment options for hypercalcemia of malignancy?

A
  1. Hydration with normal saline and loop diuretics
  2. Calcitonin (Miacalcin)
  3. IV bisphosphanates (Zoledronic Acid (Zometa)
  4. Denosumab
266
Q

Miacalcin

A

Calcitonin

267
Q

Zometa

A

IV zolendronic acid

dont confuse with Reclast which is dose yearly for osteoporosis

268
Q

Xgeva

A

Denosumab

Dont confuse with Prolia which is for every 6 months for osteoporosis

269
Q

What is Xgeva MOA?

A

Denosumab

RANKL mab that inhibits the interaction between RANKL and RANK

270
Q

Major chemo vesicants? 2 `

A

Anthracyclines

Vinca alkaloids

271
Q

How do you treat extravacation?

A

Cold compress (except with vinca and etoposide which you use warm)

Anthracycline antidote: Dexrazoxane (Totect) or dimethyl sulfoxide

Vinca antidote: Hyaluronidase

272
Q

4 drugs that can be given intrathecally and one note about them

A
  1. Cytarabine
  2. Methotrexate
  3. Hydrocortisone
  4. Thiotepa
  5. They must be preservative free
273
Q

Intrathecal admin of what drug can be fatal and what should you do to limit that chance>

A

Vincristine is fatal

Dont dispense vincristine in a syringe

274
Q

Vaccinations in Chemo?

A

Should be avoided if you need to give one give two wks prior

275
Q

What treatment regimens are used for premenopausal women? 2

Stage 1-II

A
  1. Aromatase inhibitors for 5 years total + ovarian abalation/ suppression (LHRH analgougues
  2. Or Tamoxifen for 5 years + abalation/suppression LHRH analgoues continue tamoxifen for 5 more years (10 years total) or stop endocrine therapy at 5 years if still premenopausal
276
Q

What change in breast cancer treatment should be done if a patient becomes postmenopausal during treatment? 2 bullets

Stage 1-2

A
  1. Switch to AI for 5 more years 10 years total
  2. Or tamoxifen for 5 more years 10 years total
277
Q

Postmenopausal women preferred tx?

Stage 1-2

278
Q

5 regimens for postmenopausal women?

5 bullets

Tage 1-2

A
  1. AI for 5 yrs: anastrazole, letrozole, exemestane, consider AI for 5 more years 10 years total
  2. AI for 2-3 years followed by tamoxifen for 5 year or
  3. Tamoxifen 2-3 years followed by AI 5 years total
  4. AI < 5 years or tamoxifen for 4.5-6 years followed by AI for 5 more years
  5. OR COntinue tamoxifen for 5 more years 10 years total
279
Q

If a pt is hormonal receptor negative ER-/PR- what happens?

Stage 1-2

A

Patients dont benefit from adjuvant hormonal therapy

280
Q

Visceral versus non visceral metastasis?

Treatment choices?

A

Visceral involving vital organs: life threatening: give cytotoxic chemo therapy (trestuzumab +/- pertuzumab) Mab HER2 targeted

Non: involving the skin or bone

281
Q

AI are effective in who only?

A

Postmenopausal women

282
Q

Preferred endocrine therapy in metastatic breast cancer?

4

A
  1. Abemaciclib + fulverstrant
  2. Palbociclib + fulverstrant or AI
  3. Ribociclib + + AI
  4. Fulvestrant alone
283
Q

What do AIs need to be given with if you are going to give them in premenopausal women

A

GnRH agonists

284
Q

When are SERMs used?

A

Hormone receptor positive tumors

285
Q

When are SERMs used?

A

HR posiitve tomorrow for both pre and post but AIs are more effective in post

286
Q

What is used to treat men with Breast cancer?

287
Q

2 SERMs to know?

A

Tamoxifen

Fulvestrant

288
Q

Soltamox

289
Q

Faslodex?

A

Fulvestrant

290
Q

Tamoxifen is a substrate of what 3 CYPs?

A

3A4, 2C9, 2D6

291
Q

What drug is indicated for hot flashes when taking tamoxifen?

A

Venlafaxine

292
Q

What SERM is used for prophylaxis of breast cancer?

A

Raloxifene

293
Q

SEs of SERMs? 10

A
  1. DVT/PE
  2. Menopausal symptoms
  3. hot flashes
  4. flushing
  5. edema
  6. wt gain
  7. HTN
  8. Mood changes
  9. amenorrhea
  10. vaginal bleeding/discharge
294
Q

Tamoxifen increases the risk of what?

A

uterine/endometrial cancer

Others decrease risk

295
Q

3 aromatase inhibitors?

A

Anastrazole

Letrozole

Exemestane

296
Q

Arimidex?

A

Anatrazole

297
Q

Femara

298
Q

Aromasin

A

Exemestane

299
Q

2 risks in aromatase inhibitors?

A

Higher risk of osteoporosis

Higher risk of CVD compared to SERMs

300
Q

AIs are contraindicated in?

301
Q

SEs of AIs? 13

A
  1. Edema
  2. DVT/PE
  3. bone pain
  4. osteoporosis
  5. menopausal symptoms
  6. hot flashes
  7. arthralgia/myalgia
  8. lethargy/fatigue
  9. N/V
  10. Rash
  11. hepatotoxicity
  12. Hypertension
  13. Dyslipidemia
302
Q

Tamoxifen counseling risks 3

A

Endometrial cancer

blood clots

Cataracts

303
Q

Evista?

A

Raloxifene

304
Q

Evista counseling?

A

DC 72 hours prior or during immobilization (post surgery, prolonged bed rest)

305
Q

Aromatase Inhibitor Counseling?

3

A
  1. This med is for pts who have finished menopause
  2. Common SEs, are joint pain and osteoporosis
  3. This medication should not be taken with tamoxifen
306
Q

Common SEs of ADT in prostate cancer? 5

A
  1. Hot flashes
  2. Loss of libido or impotence
  3. Gynecomastia
  4. Hair thinning
  5. Peripheral edema
307
Q

What can GnRH agonists cause?

A

Tumor flare when starting

308
Q

What is often given with GnRHs?

A

Antiandrogens to prevent symptoms of tumor flare

309
Q

Two GnRH agonists?

A

Leuprolide

Goserelin

310
Q

Lupron

A

Leuprolide

311
Q

Zoladex

312
Q

Risk of GnRH agonists 2

A

Osteoporosis risk

TUmor flare

313
Q

SE of GnRH agonist or LHRHs agonists 9

A
  1. Hot flashes
  2. Impotence
  3. gynecomastia
  4. peripheral edema
  5. bone pain
  6. injection site pain
  7. QT prolongation
  8. dyslipidemia
  9. hyperglycemia
314
Q

FIrmagon

315
Q

GnRH antagonists 1

316
Q

2 notes for GnRH antagonists

A

OSteoporosis

Does not cause tumore flare

317
Q

Added SEs of GnRH antagonists

A

Hypersensitivity Rxns

318
Q

Both GnRH agonists and antagonists cause what?

A

Have risk for osteoporosus

319
Q

First generation antiandrogens

A

Bicalutamide

320
Q

Casodex

A

Bicalutamide

321
Q

When are first gen Antiandrogens used?

A

Only used in combo with GnRH agonists

322
Q

Second gen antiandrogens

A

Enzalitamide

323
Q

Xtandi

A

Enzalutamide

324
Q

What weight is used for calculating BSA in cancer patients

A

Acutal body weight

325
Q

Mosteller Equation

A

Sqrt(ht cm * wt kg/3600)= BSA in M2

326
Q

Cell cycle not specific agents? 3 classes

A
  1. Alkylating agents
  2. Platinum based
  3. Anthracyclines
327
Q

Alkylating agents 6

A
  1. Cyclophosphamide
  2. Ifosfamide
  3. Carmustine
  4. Bendamustine
  5. Busulfran
  6. Melphalon
328
Q

What two drugs cause hemorrhagic cysitis

A
  1. Cyclophosphamide
  2. Ifosfamide
329
Q

What alkylating chemotherapy agents cuase pulmonary toxicity? 1 bolded

A

Busulfran, carmustine, lomustine

330
Q

Cyclophosphamide SE?

331
Q

Platinum drugs can cause what type of symptoms?

A

Symptoms similar to heavy metal poisoning like peripheral sensory neuropathy

332
Q

Cisplatin is associated with what 2 big SEs?

A
  1. Highest incidence of nephro tocixity
  2. Chemo induce NV
333
Q

3 unique things of Cisplatin?

A
  1. Causes nephro and ototoxicity
  2. Amifostine ethyol can be used to protect from nephro
  3. highly emetogenic
334
Q

Boxed warning for platinums?

A

Anaphylaxis like reaction occurs with repeated exposure

335
Q

Side effects of platinums?

A

Peripheral neuropathy

336
Q

Carboplatin dose calculations

A

Calvert formula

Total dose= Target AUC * (GFR +25)

337
Q

Zinecard

A

Dexarazone is chemo protect form

338
Q

What is associated with anthracyclines?

A

Cardiotoxicity

339
Q

When should Zinecard be considered?

A

Doxorubicin cumulative doses > 300`

340
Q

What should be monitored with doxorubicin?

341
Q

Unique concerns for doxorubicin? 6

A
  1. Strong vesicant
  2. Red urine discoloration
  3. lifetime cum 450-550
  4. Totect for extravacation
  5. Zinecard for cardioprotection
  6. N/V
342
Q

Boxed warnings for doxorubicin 3

A
  1. Myocardial tox
  2. vesicant
  3. myelosuppression
343
Q

What is mitoxantrone?

What does it cause?

A

Anthracycline

Causes blue urine

344
Q

Vinca alkaloids MOA?

A

inhibit function of microtubules during M phase

345
Q

Labeled warning for vinca alkaloids?

A

For IV use only fatal if given other routes

346
Q

What two things are common for vinca alkaloids

A

Peripheral and autonomic (constiplation) neuropathies

347
Q

What vinca is more associated with what toxicity

A

vinCristine: CNS toxic neiropathy

Acidental intrathecal admin and caus eparalysis and death

348
Q

2 vinca alkaloids are associated with what?

A

Bone marrow suppression

VinBlastine and vinorelBine

349
Q

Max dose of vincristine?

350
Q

How should vincristine be prepared and why?

A

In an IV piggy back to prevent acidentental death

351
Q

Wha vinca in myelosuppresive what one isnt?

What drugs can be interchanged?

A

Vinblastine causes myelosuppression

Vincrtistine doesnt

Liposomal Vincristine is not interchangable with vincrtistine

352
Q

Taxane MOA?

A

Inhibit microtubule function in M phase

353
Q

3 main side effects of taxanes?

A

Peripheral sensory neuropathies, infusion related hypersens

fatal anaphylaxis

354
Q

Taxane metabolism?

A

All are metabolized by the liver and require renal/hepatic dose adjustmetn

355
Q

Drug interactions with taxanes?

A

Elimination is reduced when given after cisplatin or carboplatin

Give taxane before platinums

356
Q

4 taxanes?

A

Paclitaxel

Docetaxel

Cabazitaxel

Paclitaxel albumin bound

357
Q

Docetaxel specific concern?

A

Severe fluid retention

358
Q

Administration note for taxanes?

A

Non-PVC bag and tubing

359
Q

Boxed warning for taxanes?

A

Hypersense rxn

360
Q

Topo I inhibitors?

A

block coiling and uncoiling of DNA during S phase

Ironotecan

361
Q

Unique concerns for Topo I inhibitor

A

Irinotecan

Acute cholnergic symptoms: atropine

Delayed diarrhea: loperamide up to 24 mg/day

362
Q

Topo II inhibitors

363
Q

Etoposide MOA?

A

uncoiling and coiling during G2 phase

364
Q

Vepsid?

A

Etoposide capsules

365
Q

Vepsid storage?

A

Refrisgerate capsules

366
Q

etoposide IV unique concerns 3`

A
  1. Infusion related rxn
  2. IV prep in concentrations <=0.4 mg/mL
  3. Non-PVC due to leaching of DEHP
367
Q

2 pyrimidine analgues and MOA?

A
  1. inhibit pyrimidine synth in S phase
  2. Flourouracil 5-fu
  3. Capecitabine
368
Q

5 FU

A

FLuorouracil

369
Q

Xeloda

A

Capecitabine

370
Q

Uniquie concerns of Xeloda 2

A

Prodrug of 5-FU

Pharmacogenomics: DPD def increase risk of severe toxicity

371
Q

5-FU unique concerns 2

A

Leucovorin is given to increase efficacy

DPD def increase toxicity

372
Q

2 folate metabolites?

A

MTX

Pemetrexed

S phase

373
Q

What may be required in folate antimetabolites? 2

A

Folic acid/analgues +/- B12

374
Q

What should be given with high doses of MTX?

A

Leucovorin or levo for rescue

375
Q

What SE is most frequently seen with what antifolate?

A

MTX nephro >=1gram/m2

376
Q

Boxed warning for antifolate?

A

Myelosuppression

377
Q

2 SEs of MTX?

A

Nephro and hepatotoxicity

378
Q

All trans Retinoic acid

379
Q

Black box for all trans retinoic acid?

A

Tretinoin

RA-APL differentiation syndrome

380
Q

Arsenic trioxide Black box 2`

A

RA-APL differentiation syndrome

QT prolongation

381
Q

Arsenic trioxide unique concerns?

A

QT prolongation

382
Q

Apariginase and Pegaspargase note

A

Peglyated form dicreases dosing interval q 2 wks and decreases allergic rxns

383
Q

SEs of Asparginase or Pegaspargase? 2

A
  1. Hypersense rxn
  2. Prolonged prothrombin time: PT/INR
384
Q

Bleomycin 2 notes

A

Not myelosuppresive

Max lifetime is 400 units due to pulm tox

385
Q

Bleomycin black box and SE

A

Pulmonary fibrpsis

Hypersense reaction

386
Q

mTor inhibitors end in?

387
Q

What is zortress and what is it used for?

A

Everolimus used for transplant

388
Q

Temsirolimus Unique concern?

A

use non-PVC bag and tubing

389
Q

mTors are substrates of what?

390
Q

4 SEs of Everolimus?

A
  1. Dyslipidemia
  2. Rash
  3. Stomatitis
  4. Lung disease interstitial
391
Q

REvlimid

A

Lenalidomide

Immunomodulator

392
Q

Revlimid Unique concern and black box? Same

A

severe birth defect

Fetal risk/pregnancy

393
Q

Thalomide

A

Thamlidomide

394
Q

What can be used with bortizomib and why?

A

Acyclovir or valacylovir to prevent herpes reactivation

395
Q

SE od bortizumib and carfilzomib

A

Peripheral neuropathy

396
Q

Monoclonal Antibodies are associated with wht?

A

infusion related rxns premed usually required

397
Q

Ci with mabs?

A

Ciculatory system

398
Q

Bevacizumab and Ramucirumab common toxicity 3

A
  1. Inhibits blood vessel growth leads to HTN and proteinuria
  2. Hemmorhage or thrombosis may occur
  3. Impaired wound healing due to decreased blood flow
399
Q

Tu for monoclonal antibodies

400
Q

Cetuxumab and Panitumab common toxicities 2

A
  1. EGFR– epidermis—skin toxiciy (anceform rash)
  2. Development of rash is correlated with reponse to therapy
401
Q

Trastuzumab and pertuzumab common tox 2

A
  1. Cardiotox
  2. Fetal-embryo
402
Q

Retuximab, Brentuxumab, Daratumumab, Inotuzumab common toxicities? 2

A
  1. Bone marrow suppression
  2. Intotuzumab ozogamicin and brentuxumab vedotin: antibody drug conjugates that bind to the cell and enable cytotoxic drug to enter
403
Q

Li

A

Immune system

404
Q

ipilimumab, Atezolizumab, Nivolumab

Pemrolizmab common tox 1

A
  1. Pts immune system becomes overactive—> potentially life threathening immune reactions
405
Q

VEGF Inhibitors 2

A

Bevacizumab

Ramucurcumab

406
Q

Avastin

A

Bevacizumab

407
Q

Cyramza

A

Ramucirumab

408
Q

Unique concerns for Avastin and Cyramza 1

A
  1. Bevacizumab, Remucircumab
  2. Impaired wound health dont give for 28 days before or after surgery
409
Q

VEGF inhibitors what to do if getting surgery?

A

Dont admin 28 days before or after surgery

410
Q

Boxed warning for Avastin and Cyramza? 2

A

Fetal embryo toxicity, GI perforation

411
Q

HER2 inhibitors 3

A

Trastuzumab

Pertuzumab

Ado-trastuzumab

412
Q

Herceptin

A

Trastuzumab

HER2

413
Q

Kadcyla?

A

Ado- Trastuzumab

414
Q

What should be monitored for HER2 inhibitors?

Kadyla, Herceptin

A

Monitor LVEF using echocardiogram or MUGA scan

415
Q

Boxed warning for HER2s

A

Kadcyla and conventional herceptin are not interchangeable

416
Q

EGFT inhibitors 2

A

Cetuxumab

Panitumumab

417
Q

Erbitux

418
Q

Vectibix

A

Panitumumab

419
Q

EGFR inhitors Erbitux and Vectibix Unique concern with pharmacogenomoics?

A
  1. Cetuximab and Panituzumab
  2. EGFR gene expression and KRAS mutation
  3. EGFR positive correlates with better response rate
  4. Must be KRAS wild type negative
420
Q

Notes for Erbitux and Vectibix? 3

A
  1. Rash indicates reponse to therapy
  2. Avoid sunlight
  3. Topical emollient inclsing steroids and abx can be used prophylaxtically to limit skin damage
421
Q

CD antigen inhibitor?

422
Q

Rituxan

423
Q

2 notes for CD inhibitors

Retuxan

A

Retuximab

  1. Premedicate with diphenhydramine APAP and steroids
  2. CD20 positive to use
424
Q

Blincyto

A

Blinatumab

C19 and CD3 positive to use

425
Q

Programmed death receptor 1 inhibitors? 2

A

Pembrolizumab

Nivolumab

426
Q

Keytruda

A

Pembrolizumab

427
Q

Opdivo

428
Q

Cytotoxic T-lymphocyte Antigen 4 inhibitor

1

A

Ipilimumab

429
Q

Yervoy

A

Ipilimumab

REMS program

430
Q

How are tyrosine kinase inhibitors given?

431
Q

What must be done in patients taking TKIs?

A

Pharmacogenomic testing

432
Q

TKI oral F?

A

May be altered with food

433
Q

TKI used in chronic myelogenous leukemia? (CML) 1

BCR_ABL inhibitors

434
Q

Gleevac

435
Q

Gleevac genetics?

A

Imatinib

must be philadelphia chromoosome (BCR-ABL) positive

436
Q

How SE of Gleevac

A

Imatinib

Fluid retention

437
Q

BRAF inhitors used in melonoma 2

A

Trametinib and Coniteinib

BRAF V600E ot V600K mutation positive to use

Warning new malignancy

438
Q

EGFR inhibitors pharmacogenetics

A

EGFR positive to use

439
Q

SEs of EGFR inhibitors 2

A

Acneform rash, dry skin

440
Q

ALK inhibitors

A

ALK positve to use

441
Q

Lapatinib and Neratinib

A

HER2 overexpression

442
Q

Special instructions FOr oral Cancer agents 3 drugs

Theo and Lena eat Poms

A

Thamidomide, pomalidomide, lenalidomide are teratogenic

443
Q

4 anticancer meds that should be given with food or 1 hour after a meal

A
  1. Gleevac (Imatinib)
  2. Thalomid (Thalidomide)
  3. Xeloda (Capecitabine)
  4. Aromasin (Exemestane)
444
Q

What anticancer drug is taken 2 hours before or 2 hours after food?

A

Pomalidomide

445
Q

6 drugs that should be taken on an empty stomach 1 hour before or two hours after food

A
  1. Nilotinib
  2. Erlotinib
  3. Sarofinib
  4. Temozolamide
  5. Abiraterone
  6. Pomalidomide
446
Q

How does the CNS control functions of the body? 2 main systems

A
  1. Through the peripheral nervous system
    1. SOmatic nervous system
    2. autonomic nervous system
447
Q

What does the somatic nervous system do?

A

COntrols muscle movements

448
Q

The somatic nervous system controls muscle moves by?

A
  1. By sending signals through neurons to release
    1. Acetylcholine Ach to act on nicotinic receptors
449
Q

What is the parasympathetic nervous system known as?

A

The rest and digest system

450
Q

The sympathetic nervous system is also known as?

What three things does it result in?

A

Also known as fight or flight

  1. Increase in
    1. Blood pressure
    2. HR
    3. and glucose production
451
Q

The sympathetic nervous system works by?

A

releasing epinephrine and nerepinephrine

to act on the adrenergic receptors (aplha 1, beta 1 and beta 2)

452
Q

Alpha 1 agonism causes what two things?

A

increased Vasoconstriction and BP

453
Q

Antagonism of the alpha 1 receptor causes what?

A

Vasodilation through smooth muscle relaxation and decrease BP

454
Q

Beta 1 agonism causes what two things?

A

Increased CO and HR

455
Q

One alpha 1 agonist?

A

Phenylephrine

456
Q

Example of beta 1 agonist?

A

Dobutamine

457
Q

Examples of two vasopressors?

A

Epinephrine and NE

458
Q

What do Epi and NE do? Leads to what 3 things?

A

Stimulate multiple receptors including alpha 1 and beta 1, b2

WHich leads to increased vaso constriction HR and BP

459
Q

What is clonidine?

A

Central acting alpha 2 adrenergic agonist

460
Q

What happens when alpha 2 receptors in the brain on stimulated?

A

Decrease in overall sympathetic output

461
Q

Dopamine dosing? 3 bullets

A
  1. Dopamine stimulates different receptors depending on dose
  2. Low renal dosing: 1-4 mcg/kg/min: Dope 1 agonist
  3. Medium: 5-10 mcg/kg/min Beta 1 agonist
  4. High: 10-20 mch/kg/min: Alpha 1 agonist
462
Q

What 3 things do vasopresssors cause

A
  1. Vasoconstriction
  2. Increased SVR
    1. which increases BP
463
Q

4 vasopressors

A
  1. Dopamine
  2. Epinephrine
  3. NE
  4. Vasopressin
464
Q

Adrenalin and Epipen?

MOA?

A

Epinephrine

A1,B1,B2 agonist

465
Q

Levophed?

MOA?

A

NE

Alpha 1> B1 agonist

466
Q

Boxed warning for vasopressors?

A

Dopamine and NE have Black boxes for extravacation

But all are vesicants

It should be treated with phentolamine

467
Q

How is vesication with vasopressors treated?

A

Phentoloamine

468
Q

5 SEs of vasopressors

A
  1. Arrythmias
  2. Tachcardia
  3. necrosis gangrene
  4. Bradycardia with phenylephrine
  5. Hyperglycemia with epinephrine
469
Q

What should be monitored all the time with vasopressos?

A

Continuos BP monitoring

470
Q

When should vasopressor solutions not be used?

A

If they are discolored or contain a precipitate

471
Q

How are vasopressors given?

A

Through IV central line

472
Q

Epinephrine concentration used for IV push

A

0.1 mg/ml 1:10,000 ration strength

473
Q

Ration strenght for IM or compounded epinephrine?

474
Q

How does phentolamine work?

A

Alpha 1 antagonist

475
Q

Vasodilators 2

A

Nitroglycerin

Nitroprusside

476
Q

Nitroprusside, Nipride

A

Nitroprusside

477
Q

Doses of nitroglycerin pertaining to its effects 2

A
  1. Low: venous vsaodilation
  2. High: arterial vasodilation
478
Q

Nitroglycerin contraindications? 3

A
  1. SBP<90
  2. Use with PDe-5
  3. Ricoguat
479
Q

3 SEs of nitroglycerin?

A
  1. HA
  2. tachycardia
  3. tachyphylaxis
480
Q

Nitroglycerin notes?

A

Need non PVC container glass, polyolefin

481
Q

Nitropress, Nipride MOA?

A

Equal venous and arterial vasodilation

482
Q

Boxed warning for Nitropress, Nipride? 3

A
  1. Metabolism leads to cyanide
  2. Excessive hypotension
  3. Not for direct injection must be further diluted with D5W
483
Q

Warning for Nitroprusside?

A

Increase Inctracranial pressure

484
Q

3 SEs of Nitroprusside?

A
  1. HA
  2. Tachycardia
  3. Thiocyanate/cyanide toxicity (Increase risk in renal and hepatic impairment
485
Q

Nitroprusside: Thiocyanate/cyanide roxicity risk is increased when what?

A

PAtients have renal or hepatic impairment

486
Q

Administrations notes for Nitroprusside?

A
  1. Protect from light during admin
  2. Use clear solutions only a blue color indicated cyanide formation
487
Q

If nitroprusside is hat color?

A

Blue indicated cyanide formation dont use

488
Q

Nitroglycerin or NTG uses?

A

During MI or uncontrolled hypertension but efficacy is limited to 24-48 hours due to tachyphylaxis (tolerance)

489
Q

What is used to prevent cyanide toxicity with nitroprusside?

A

Hydroxocobalamin

Sodium thiosulfate is used for cyanide toxicity

490
Q

What does nesiritide do?

A

Recombinant B-type natriuttic peptide

Binds to vasuclar smooth muscle and increases cGMP

491
Q

What do inotropes do?

A

Increase contractility of the heart

492
Q

Two inotropes to know?

A

Dobutamine

Milrinone

493
Q

How does dobutamine work?

A

B1 agonist

Increases HR and force of contraction

Which increases cardiac output

494
Q

How does milrinone work?

A

PDE-3 inhibitor

Produces inotropic effects with significant vasodilation

495
Q

Special note for dobutmaine?

A

Way turn pink due to oxidation but potency is not lost

496
Q

Crystalloids versus Colloids

Which one is less costly and generally has fewer adverse effects?

A

Crystalloids

497
Q

What are colloids?

A

large molecule typically proteins or startch

Remain in the intravascular space and increase oncotic pressue

498
Q

When is dextrose used pertaining to fluids

A

when water is needed intracellularly

These products contain free water

499
Q

Most common fluids used when volume rescusitation is needed in shock state?

A

Lactate ringers and NS

500
Q

What is the most common colloid?

501
Q

When is albumin particularly useful?

A

WHen there is significant edema (cirrhosis)

502
Q

Hydroxyethyl startch boxed watning?

A

Limited by box warning for use in critically ill including sepsis due to increase mortalitiy

503
Q

Crystalloids 3

A

Dextrose

NS

LActate ringers

504
Q

Colloids 3

A

Albumin

Dextran

Hydoxyethyl startch

505
Q

Albuminar, Albutein, Alburx

A

Albumin 5% and 25%

506
Q

General principles for treating shock 3

A

1. Fill the tank

1. Optimize preload with IV crystalloids bolus as needed 2. Squeeze the pipes
1. Peripheral vasocontrictors (a1agonists) to increase systemic vascular resistance 3. Kick the pump
1. B1 agonist to increase myocardial contractility and cardiac output
507
Q

How is shock usually caused and defined?

A

Hypoperfusion

Hypotension: SBP <90

MAP <70

508
Q

What are the 4 types of shocK?

A
  1. Hypovolemic (hemorrhage)
  2. Distributive (eptic, anaphylactic)
  3. Cardiogenic (post MI)
  4. Obstructive
509
Q

What is first line for hypovolemic shock?

A

IV crystalloids

In pts with hypovolemic chock that is not caused by hemorrhage

510
Q

When are vasopressors not effective?

A

If intravascular volume is not adequate

511
Q

How is sepsis defined?

A

Life-threatening organ dysfunction due to dysregulated host response to infection

512
Q

Common ICU infections

2 ones

A

Mechanical ventilations

foley catheter

513
Q

Increased time on ventilator increases risk of infection what is a common pathogen?

A

Pseudomonas they like moist air

514
Q

Increasd time with foley catheter does one?

A

Increase chance of bladder infection

515
Q

treatment for sepsis and septic shock?

A

Broad spectrum abx and IV fluid resucitation with IV crystalloids

516
Q

What is the vasopressor of choice in septic shock?

517
Q

Acute decompensated HF and cardiogenic shock

What is it?

A

Acute decompensated heart failure

rapid decline in health, wt gain, worseing of symptoms

518
Q

What has to be present to characterize acute decompensated heart failure to cardiogenic shock?

A

Hypoperfusion and hypotension

519
Q

When is a ADHF patient considered volume overloaded?

A

Edema, ascites, jugular venous distention

520
Q

Treatment options for volume overloaded ADHF patients? 2

A

Loop diuretics

vasodilators can be added

521
Q

How is hypoperfusion characterized? 3 things

A
  1. Decreased renal function
  2. ALtered mental status
  3. or cold extremities
522
Q

2 treatment options for ADHF patient experiencing hypopurfusion?

A
  1. Intoropes : dobutamine, milrinone
  2. If pt become hypotensiove consider adding vasopressor, NE, dopamine, or phenylephrine
  3. Avoid vasodilators become they can decrease BP and worsen
523
Q

What should pts be treated with if they have both volume overload and hypoperfusion

A

Both sets of agents

Loops, but avoid vasodilators

524
Q

When should BBs be stopped in patients with ADHF?

A

If hypotension or hypoperfusion is present

525
Q

What can be used for invasive monioring?

What does it do?

A

Catheter called Swan Ganz

  1. Measures congeestion pulmonary cap wedge pressure
526
Q

Treating volume overload?

A

Loops and IV vasodilators

527
Q

What 2 drugs are uniquely suited for hypoperfusion?

A

Dobutamine and milrinone

528
Q

Common ICU conditions

Pain?

A

IV pioids

morphine and fentanyl first line

529
Q

Strategy when pain in ICU?

A

Analgesosedation: sedation strat that used analgesics first

530
Q

What is preferred for sedation in ICU patients?

A

Non-BZDs are preferred propofol and dexmedomadine

531
Q

How is agitation managed in the ICU?

A

WIth BZDs: lorazepam or midazolam

532
Q

What is the only sedative approved for intubated and nonintubated patients?

A

Dexmetomadine

533
Q

Benzos role in sedation two times?

A

Seizure patients

and

Alcohol withdrawal patients

534
Q

What type of sedation is preferred?

A

Light sedation

535
Q

What is used to assess someones readiness to get off of sedatives?

A

Sedation vacaiton baby!`

`

536
Q

What can decrease the risk of delerium in ICU patients?

A

Using non BZDs and or shorten the suration

537
Q

What drug can be useful for delirium in ICU patients?

A

Quitiapine

538
Q

Dilaudid?

A

Hydromorphone

539
Q

Precedex?

A

Dexmedetomidine

540
Q

How does precedex work?

A

A2 adrenergic agonist

541
Q

SEs of precedex 3?

A
  1. Hypotension
  2. HYpertension
  3. bradycardia
542
Q

How long should the infusion for precedex be?

A

Duration should not be longer than 24 hours

543
Q

Used of precedex?

A

Sedation in intubated and not intubated patients

544
Q

Diprivan?

545
Q

Contraindications to propofol?

A

hypersesitivity to eggs or soy

546
Q

SEs of Diprivan

A

Hypotension, apnea, hypertg, green urine/hair/nail beds, propofol related infusion syndrome (PRIS) can be fatal

547
Q

What should be monitored for propofol?

A

Triglycerides with given for more than 2 days

548
Q

Notes for propofol?

A

bacterial growth discard vial and tubing within 12 hours

549
Q

What does propofol give you?

A

Oil in water emulsion give 1.1 kcal/mL

550
Q

Ativan

551
Q

Note about Ativan injection?

A

formulated in propylene glycol prop glycol toxicity: can ccause acute renal failure and metabolic acidosis

552
Q

Versed?

553
Q

Contraindication to Versed?

A

Strong CYP3A4 inhibitors

554
Q

Note about midazolam?

A

Can accumulate in obese patients and renal impariment (active metabolite)

555
Q

Monitoring for Etomidate?

A

Adrenal insufficiency

556
Q

Ketamine Warnings?

A

Emergence reactions vivid dreams hallucinations delerium

557
Q

Haldol

A

Haloperidol

558
Q

Seroquel?

A

Quetiapine

559
Q

What is recommended for stress ulcers in ICU patients?

A

H2RAs and PPIs

560
Q

What 3 things have PPIs been associated with?

A

Bone fracture, C Diff, Nosocomial Pneumonia

561
Q

What anesthetic can be fatal IV?

A

Bupivicaine

Commonly used in epiderals

562
Q

Local anesthetic?

563
Q

Xylocaine?

564
Q

Inhaled anesthetics? 2

A

Desflurane, sevoflurane

565
Q

Suprane

A

Defsflurane

566
Q

Injectable anesthetics? 2

A

Bupivacaine, ropivicaine

567
Q

What combo is sometimes used for local procedures, anesthetic

A

Lidocaine/Epi

568
Q

What does epinenephrine do in the lidocaine/Epi combo?

A

Vasoconstriction and keeps the lido locals

pretty neat!

569
Q

Risk factors to develop Stress ulcers? 2

A

Mechanical ventilation and coagulopathy

570
Q

When are neuromuscular blockers used? 4

A
  1. During surgery
  2. To help with mechanical ventilation
  3. TO manage increase ICP
  4. Treat muscle spasms
571
Q

What do you need to make sure before giving someone NMBA? 2

A
  1. Ensure adequate sedation and analgesia
  2. Must be mechanically ventilated
572
Q

Label for NMBA?

A

Warning paralyzing agent

573
Q

What is the only available depolarizing NMBA?

A

Succinylcholine

574
Q

What is succinylcholine typically reserved for?

A

Intubation

575
Q

What special care needs to be taken with NMBA?? 3

A
  1. Ensure eye lubrication
  2. Airway suction
  3. Protect the skin
576
Q

What can be used to reduce airway secretions when using NMBA?

What does it do?

A

Glycopyrolate

Anticholinergic

577
Q

Quelicin?

A

Depolarizing NMBA

Succinylcholine

578
Q

4 SEs for all non-depolarizing NMBA?

A

Bradycardia, flushing, hypotension, tachyphylaxis

579
Q

Nimbex?

A

Cisatracurium

580
Q

Nimbex Notes

A

Hofmann elimination: independent of renal and hepatic impairment

581
Q

Pancuronium?

A

Long acting agent

582
Q

How do systemic hemostatic agents work?

A

By inhibiting fibrinolysis and enhancing coagulation

583
Q

2 topical hemostatic agents?

A

Recothrom, Thrombin JMI

584
Q

Cyklokapron?

A

Tranexamic acid

Hemostatic

585
Q

Lysteda?

A

Tanexamic acid: tablet

586
Q

What is lysteda used for?

A

Heavy menstrual bleeding: mennorhagic

587
Q

Novoseven RT?

A

Recombinant factor VIIa

Hemostatic

588
Q

IVIG uses? 4

A
  1. Used to only be indicated for immunodef conditions
  2. Now has many uses, MS, myathenia gravis, guilliane barr
589
Q

Treating with IVIG can do what?

A

impair response to vaccines

590
Q

Carimune NF, Flebogamma DIF, Gammagard, Gamunex-C, Octagam, Privigen

591
Q

How is Carimune NF, Flebogamma DIF, Gammagard, Gamunex-C, Octagam, Privigen, dosed?

592
Q

Administration note for IVIG?

A

Use slower infusions rate for renal and CV disease

593
Q

Boxed warnings for Carimune NF, Flebogamma DIF, Gammagard, Gamunex-C, Octagam, Privigen

2

A
  1. Acute renal dysfunction, usually within 7 days, more likley with products stabalized by sucrose
  2. THrombosis
594
Q

SEs of Carimune NF, Flebogamma DIF, Gammagard, Gamunex-C, Octagam, Privigen

10

A
  1. HA
  2. Nausea
  3. diarrhea
  4. injection site rxn
  5. infusion rxn, facial flushing, chest pain, tightness, fever, chills, hypotension- slow/stop infusion
595
Q

How is hyponatremia defined?

A

Na <135 meq/L

596
Q

How is hypovolemic hyponatremia caused? 5

A
  1. Diuresis
  2. salt wasting syndromes
  3. blood loss
  4. vomitting and diarrhea
597
Q

How is hypovolemic hyponatremia treated?

A

Sodium chloride containing products IV

598
Q

How is hypervolemic hyponatremia caused?

A

fluid overload, cirhosis, HF, renal failure

599
Q

How is hypervolemic hyponatremia treated?

A

Duiretics and fluid

600
Q

How is isovolemic hyponatremia caused?

A

COmmonly caused by Syndrome of Inappropriate antidiuretic hormone

SIADH

601
Q

What can be used to treat SIADH and hypervolemic hyponatremia?

A

arginine vasopressin receptor antagonists (AVP)

602
Q

What is the safe way to correct sodium?

A

12 meq/L over 24 hours

More rapidly can cause osmotic demethylation syndrome (ODS)

or central pontine myelonolysis

can cause paralysis, seizure and death

603
Q

Samsca?

A

Talvaptan

Arginine vasopressin receptor antagonist

604
Q

How long should a pt be treated with Samsca?

A

Talvaptan AVP

limited to less than <=30 days due to hepatotoxicity

605
Q

2 boxed warnings for Samsca?

A

Talvaptan

  1. Intiated and re-initiated in hospital
  2. Overly rapid correction of hyponatremia >12 meq/L/24 is associated with ODS
606
Q

SEs of Samsca? 4

A

Thirst, nausea, dry mouth, polyuria

607
Q

Warning for Samsca?

A

Hepatotoxicity

608
Q

What to monitor for samca?

A

Rate of Na increase

609
Q

How is hypernatremia defined?

What is it associated with?

A

Na>145 meq/L

Water deficiency and hypertonicity

610
Q

How is hypokalemia defined?

A

K<3.5 mEq/L

611
Q

Common causes of Hypokalemia?

A

Underlying causes usually, meds, amphotericin and insulin

612
Q

K deficiency related to total body

A
  1. 1mEq drop in serum below 3.5
    1. Indicated a total def of 100-400meq
613
Q

Max infusion rate and max concentration of IV potassium chloride?

A

>=10mEq/hr

max concentration of 10 mEq/100 mL

614
Q

How can potassium chloride kill you?

A

IF it is not diluted or given via IV push

615
Q

What is needed for potassium?

A

Mg must be corrected

616
Q

When is IV mg recommended?

A

When Mg <1mEq/L with life threatening symptoms (seizure or arrythmias)

617
Q

What is used for IV mg replacement?

A

Mg sulfate

618
Q

Common oral mg agent?

619
Q

When is hypophosphetemia life threatening?

620
Q

When is IV phos used?

A

PO4 is < 1mg/dL

NAPLEX (64 decks)

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