Oncology Part II Flashcards
Trastuzumab (Herceptin)
Mechanism
Binds to human epidermal growth factor receptor 2 (HER2)
Trastuzumab (Herceptin)
Key Safety Concerns
Cardiotoxicity (eg, cardiomyopathy)
Monitor LVEF before & after treatment
Bevacizumab (Avastin)
Mechanism
Binds to vascular endothelial growth factor (VEGF)
Bevacizumab (Avastin
Key Safety Concerns
Impaired wound healing
* Avoid for 28 days before or after surgery
Thromboembolic events
Hemorrhage/fatal bleeding
Gl perforation
Programmed Death Receptor-1 (PD-1) inhibitors
Drugs
Pembrolizumab (Keytruda)
Nivolumab (Opdivo)
Cytotoxic T-Lymphocyte Antigen-4 (CTLA-4) Inhibitor
Drug
Ipilumumab (Yervoy)
Key Safety Concerns
PD-1 & CTLA-4
Immune-mediated toxicities (eg, endocrinopathies, colitis, hepatotoxicity)
Identifying Prostate Cancer
Abnormal DRE + PSA > 10 ng/mL
Gonadotropin-releasing hormone (GnRH) agonists
Common drugs
Leuprolide (Lupron Depot)
Goserelin (Zoladex)
Histrelin (Supprelin LA)
Triptorelin (Trelstar)
Gonadotropin-releasing hormone (GnRH) agonists
Safety concerns
↓ bone density
* Prevent with calcium & vitamin D
- Tumor flare
- Give with antiandrogen
- Hot flashes
- Impotence, gynecomastia
- Bone pain
- QT prolongation
Gonadotropin-releasing hormone (GnRH) antagonists
Common drugs
Degarelix (Firmagon)
Relugolix (Orgovyx)
Gonadotropin-releasing hormone (GnRH) antagonists
Safety concerns
Hot flashes
Antiandrogens
Common drugs
Bicalutamide (Casodex)
Flutamide
Nilutamide (Nilandron)
Antiandrogens
Safety concerns
Hot flashes
Gynecomastia
Hepatotoxicity
Vinca Alkaloids
Drugs
Vincristine
Vinblastine
Vinorelbine
Vinca Alkaloids
Side Effects
Peripheral sensory neuropathy (paresthesias)
Autonomic neuropathy (gastroparesis, constipation)
Vinca Alkaloids
Peripheral neuropathy
Monitor S/Sx (eg, numbness, paresthesia, pain)
Prevention: Limit single vincristine doses to 2 mg
Tx: Neuropathic pain medications (eg, gabapentin, duloxetine)
Vinca Alkaloids
Autonomic neuropathy
Monitor S/Sx (eg, Bowel movement frequency)
Prevention & Tx: Symptomatic care (eg, diet modifications, laxatives)
Vinca Alkaloids
Administration
Only IV
Prepare in a small IV bag
Tretinoin
Safety Concern
Differentiation syndrome (fever, dyspnea, pleural effusion)
Tretinoin
Management
Systemic steroids (eg, dexamethasone)
Interrupt therapy
Arsenic trioxide
Safety Concern
QT prolongation
Arsenic trioxide
Management
Maintain K > 4 and Mg > 1.8 mEq/L
Avoid QT-prolonging drugs
Bleomycin
Safety Concern
Pulmonary toxicity (eg, pulmonary fibrosis)
Hypersensitivity reactions
Bleomycin
Management
Limit lifetime cumulative dose to 400 units
Test dose and/or premedicate
Bortezomib & Carfilzomib
Safety Concern
Proteasome Inhibitors
Herpes reactivation
Bortezomib & Carfilzomib
Management
Proteasome Inhibitors
Antiviral agents (eg, acyclovir, valacyclovir)
Immunomodulators Meds
Lenalidomide (Revlimid)
Pomalidomid (Pomlyst)
Thalidomide (Thalomid)
Lenalidomide, Pomalidomid, & Thalidomide
Safety Concern
Immunomodulators
Sever birth defects (need 2 negative pregnancy tests)
Thrombosis (DVT/PE)
Lenalidomide, Pomalidomid, & Thalidomide
Management
Immunomodulators
REMS program
2 form of contraception or abstain from sex
PPx anticoagulation
Pegaspargase
Safety Concerns
Modified from of L-asparaginase conjugated w/ polyethylene glycol
Hypersensitivity Reactions
Pegaspargase
Management
Modified from of L-asparaginase conjugated w/ polyethylene glycol
Premedication w/ APAP, diphenhydramine & an H2RA
Whatdoes rituximab target?
A. EGFR
B. VEGF
C. CD20
D. HER2
E. PD-1
CD20
Brand (Rituxan)
Rituximab binds to the CD-20 antigen on the B-cells, so patients must be CD20 positive in order to use rituximab.
CD refers to the Leukocyte Cluster of Differentiation antigens.
On day 5 of the chemotherapeutic regimen, he complains of tingling, numbness and pain in his fingers. Which of his chemotherapeutic medications is most likely causing these symptoms?
A. Rituximab
B. Cyclophosphamide
C. Doxorubicin
D. Vincristine
E. Prednisone
Vincristine
Vincristine is notable for causing peripheral neuropathies.
Which agents are cell cycle independent?
Alkylating agents (eg, cyclophosphamide)
Anthracyclines (eg, doxorubicin)
Platinum compounds (eg, cisplatin)
Which agents work on the S phase?
Antimetabolites (eg, methotrexate)
Topoisomerase I inhibitors (eg, irinotecan)
Which agents works on the G2 phase?
Etoposide
Bleomycin
Which agents works on the M phase?
Taxanes
Vinca alkaloids
Pyrimidine analog antimetabolites
MOA
S phase
Incoporates into DNA by interfering w/ certain nucleotides in RNA & DNA
Flurorouracil inhibits thymidylate synthase
Pyrimidine analog antimetabolites
Drugs
Fluorouracil
Capecitabine
Capecitabine is converted into Fluorouracil
Pyrimidine analog antimetabolites
What is given w/ fluorouracil to ↑ efficacy?
Leucovorin or
Levoleucovorin
Pyrimidine analog antimetabolites
Adverse Effects
Hand-Foot Syndrome (Palmar-Plantar Erythrodysesthesia)
GI Toxicities: Diarrhea, mucositis
Severe toxicities ↑ w/ dihydropyrimidine dehydrogenase (DPD) deficiency
DPD breaks down Fluorouracil
Hand-Foot Syndrome (Palmar-Plantar Erythrodysesthesia)
Monitoring
S/Sx (eg, painful erythema, skin peeling)
Hand-Foot Syndrome (Palmar-Plantar Erythrodysesthesia)
Management
Limit daily activities to reduce pressure to hands & feet
Avoid heat exposure
Apply cold compresses for temporary relief
Use emollients or topical steroids
Modify doses or interrupt therapy for severe cases
Dihydropyrimidine dehydrogenase (DPD) deficiency
Prevention
Pharmacogenomic testing
Dihydropyrimidine dehydrogenase (DPD) deficiency
Treatment of toxicities
Antidote: uridine triacetate for overdose or early-onset toxicity
Symptomatic care (specific to the toxicity)
Pyrimidine analog antimetabolites
Drug intxn
Warfarin:
Monitor INR (↑) & S/Sx of bleeding
Folate Antimetabolites
MOA
S phase
Inhibits dihydrofolate reductase → inhibits tetrahydrofolate activation → inhibiting purine & pyrimidines synthesis
Folate Antimetabolites
Toxicities
Nephrotoxicity (w/ high doses ≥ 500 mg/m2)
GI toxicity (eg, diarrhea, mucositis)
Folate Antimetabolites: Nephrotoxicity
Monitoring
Renal function (eg, BUN, SCr)
Wt gain
Urine pH (target ≥ 7)
Methotrexate levels
Folate Antimetabolites: Nephrotoxicity
Prevention
Leucovorin or levoleucovorin “rescue”
IV sodium bicarbonate hydration to alkalinize the urine
Avoid interaction meds (eg, NSAIDs, salicylates)
Folate Antimetabolites: Nephrotoxicity
Treatment
Antidote: glucarpidase rapidly lowers MTX levels
Folate Antimetabolites: GI toxicity
Monitoring
S/Sx (eg, BM frequency, painful mouth ulcers)
Folate Antimetabolites: GI toxicity
Prevention & Treatment
Diarrhea: antidiarrheals, hydration, electrolyte repletion
Mucositis: various
Leucovorin or levoleucovorin “rescue”
Folate Antimetabolites: GI toxicity: Mucositis
Monitoring
S/Sx (eg, painful mouth ulcers, difficulty eating)
S/Sx of infections (eg, thrush)
Folate Antimetabolites: GI toxicity: Mucositis
Prevention
Good oral hygiene (eg, brushing with a soft toothbrush)
Hold ice chips in the mouth
Frequent rinsing with bland rinses (eg, sodium bicarbonate solution)
Folate Antimetabolites: GI toxicity: Mucositis
Treatment
Continue good oral hygiene and frequent rinsing
Symptomatic care (eg, viscous lidocaine 2%, magic mouthwash)
Parenteral nutrition or IV hydration in some cases
Thrush treatment (eg, nystatin oral suspension, clotrimazole troches) if indicated
Tyrosine Kinase Inhibitors
Bind to BCR-ABL fusion gene
Imatinib (Gleevec)
Dasatinib (Sprycel)
Nilotinib (Tasigna)
Tyrosine Kinase Inhibitors: Bind to BCR-ABL fusion gene
Safety Concerns
Fluid retention
QT prolongation (nilotinib [Tasigna] ← greatest risk)
* Assess QT interval with an ECG
* Correct electrolyte abnormalities
* Avoid concurrent QT-prolonging drugs & strong CYP3A4 inhibitors
Gl upset (eg, abdominal pain)
* Take imatinib with food
Tyrosine Kinase Inhibitors
Bind to protein kinase BRAF
Dabrafenib (Tafinlar)
Vemurafenib (Zelboraf)
Tyrosine Kinase Inhibitors: Bind to protein kinase BRAF
Safety Concerns
New malignancies
QT prolongation
Tyrosine Kinase Inhibitors
Bind to mitogen-activated extracellular kinase (MEK)
Cobimetinib (Cotellic)
Trametinib
Tyrosine Kinase Inhibitors: Bind to MEK
Safety Concerns
Retinopathy
Rhabdomyolysis
Tyrosine Kinase Inhibitors
Bind to epidermal growth factor receptor (EGFR)
Afatinib (Gilotrif)
Erlotinib (Tarceva)
Tyrosine Kinase Inhibitors: EGFR
Safety Concerns
Dermatologic toxicity (eg, acneiform rash)
Use general skin care (eg, sunscreen) & PPx measures (eg, antibiotics)