Pharm Exam Heme/Onc Flashcards
What does type 4 hyper sensitivity reaction have to do with?
Inflammation
What are the Cardinal Signs of Chronic inflammation
There are no cardinal signs for chronic inflammation
5 classic signs of inflammation
pain Heat Redness Swelling Loss of function
Steroid Side effects
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Wheel O side effects
Short acting Glucocorticoids
Hydrocortisone
Cortisol
Cortisone
Intermediate acting Glucocorticoids
Prednisone
Prednisolone
Methylprednisolone
Triamcinolone
Long acting Glucocorticoids
Dexamethasone
Betamethasone
Hydrocortisone 2.5% cream
Responsive Dermatomes
Contraindications
Do not use super potent from on face, groin, axillae
Exclude viral diseases i.e. chicken pox, measles
Adverse:
Burning, stinging, pruritis, erythema, skin atrophy
Prednisone
Glucocorticoid
Interactions:
Barbiturates may decrease effects,
potentiated by ketoconazole
Contra:
Fungal, live vaccines
Warnings:
Strongyloidies, hypothyroidism, ocular herpes, cirrhosis, renal failure, hypertension, osteoporosis, diabetes, Tuberculosis, amebiasis
Adverse:
infection, glaucoma, cataracts, hypokalemia, hypocalcemia, hypernatremia, hypertension, CHF, psych, osteoporosis
Dexamethasone
Injection, IV, IM, joint, intra-lesion
Glucocorticoid
When oral therapy is not feasible
Contra:
Systemic fungal, Live vaccine
Adverse:
can mask infections, infection, glaucoma, cataracts, hypokalemia, hypocalcemia, hyponatremia, hypertension, CHF, psych, osteoporosis, hyperglycemia
Where does histamine come from?
Mast Cells
Histamine H1 receptors
smooth muscle contraction increasing capillary permeability
Histamine promote vasodilation through release of Nitric Oxide
H1 receptors mediate pathological response like allergic reaction, atopic derm, conjunctivitis, urticaria, bronchoconstriction, asthma, anaphylaxis
Smooth muscle, vasc perm via NO, Skin Resp
Examples of H1 receptor blockers
diphenhydramine
Cetirizine
Loratadine
Examples of H2 receptor blockers
Cimetidine
Ranitidine
H2 receptors mediate
Gastric acid secretory action of histamine
H1 receptors mediate
smooth muscle contraction increased vascular permeability pruritus Prostaglandin generation Decreased AV conduction time + Tachycardia
VAPPS
First generation H1 receptor blockers
Diphenhydramine
Why use 2nd generation Antihistamines
they reduce allergic response with little to no sedation
Examples of 2nd generation Antihistamines
Cetirizine
Loratadine
Fexofenadine
Side effects of antihistamine
same as anticholinergics
Hot Red Dry Blind Mad
diphenhydramine
antihistamine
Interactions:
potentiates CNS depression with alcohol & other CNS depressants
Adverse: Drowsiness, dizziness, anticholinergic effects, excitability in children
25-50mg q4-6 max 300mg
Warnings:
Asthma, resp disorders, glaucoma, hyperthyroidism, hypertension, CVD, Pregnancy Cat B in 3rd trimester, not recommended
Cetirizine
Allergic rhinitis
Interactions:
potentiates CNS depression with alcohol & other CNS depressants
Adverse:
Drowsiness, somnolence, fatigue, dry mouth
Causes of microcytic Anemia
TICS
Thalassemia
Iron deficiency
Chronic disease
Sideroblastic
Causes of normocytic anemia
Aplasia
Renal disease
inflammation
Chronic disease
Causes of macrocytic anemia
B12 deficiency
Folate deficiency
Myelodysplasia
Alcohol
MCV over 100
Thalassemia
Hgb H
Thal A = need folic acid supplements
avoid iron and oxidative drugs like dapsone, quinidine, primaquine, sulfonamides, nitrofurantoin
Thal B Major needs transfusions to keep levels at 12g/dl
Iron overload may result in hemosiderosis, HF, cirrhosis, endocrinopathies
DQPSN
dapsone, quinidine, primaquine, sulfonamides, nitrofurantoin
Deferoxamine
Acute iron intoxication
Chronic iron overload (multiple transfusions)
Iron chelating agent
Contra:
Renal disease, anuria
Ferrous sulfate
Iron deficiency, iron anemia
325mg TiD
Contra:
Hemochromatosis
Hemosiderosis
Interactions
Tetracycline (inhibits)
Adverse:
Nausea, abdominal discomfort, pain, constipation, diarrhea
Anemia of chronic disease (inflammation)
diseases
Chronic infections: TB Chronic UTI neoplastic Liver disease from ETOH Hyperthyroidism/hypothyroidism auto immune SLE/RA
TTULAC
Anemia of chronic disease (inflammation)
Treatment
treat underlying cause
possible transfusion
EPO
No iron
Cause, Transfusion, EPO, no Iron
Sideroblastic anemia
B6 deficient, fix with B6
Chronic Alcoholism, B6 deficiency
Tx: treat underlying disease
chelating agent for lead
transfusion,
remove toxins
What is pernicious anemia
decrease in red blood cells when the body can’t absorb enough vitamin B-12
Who is at risk for pernicious anemia
Vegan, vegetarian diet, gastric or bariatric surgery
B12 MOA
Conversion of homocysteine to methionine
Conversion of L methylmalonyl CoA to succinyl CoA
Medicines that lead to B12 deficiency
Metformin
Colchicine
Folic Acid
megaloblastic anemia with folic acid deficiency from nutrition, pregnancy, childhood
Pregnancy cat A
May antagonize phenytoin
False low serum and red cell folate levels may occur with antibiotics (i.e. tetracycline)
Phenytoin, tetracycline, Cat A
Hemochromatosis Tx
Iron chelating agent
IV deferoxamine or PO defrasirox
Hereditary Hemochromatosis Tx:
Phlebotomy
Hemolytic anemia
SPIRE
Splenectomy Prednisone IVIG Rituximab EPO
Rituximab
CD20 directed cytolytic monoclonal antibody
Adverse: Fatal infusion related reaction Severe mucocutaneous reactions Hep B virus reactivation Progressive multifocal leukoencephalopathy
IVIG
IV immune globulin
Indications:
ITP Immune thrombocytopenia
AIHA Autoimmune hemolytic anemia
Hydroxurea
reduces the need for transfusion in sickle cell, reduces pain
Warning: Myelosuppression, malignancy
Kills babies (fetal tox)
Adverse:
Leukopenia, Thrombocytopenia, anemia, neutropenia, GI upset, anorexia, hair loss
MOA:
Improved tissue oxygenation and decreased inflammation
Transfusion reaction treatment
Supportive
benadryl allergic reactions (mild)
tylenol for fever
Secondary causes of polycythemia vera
Tobacco use
Living at high altitude
Polycythemia vera treatment
Serial phlebotomy
one major cause of reactive thrombosis
inflammation
Treatment for VTE (DVT/PE)
Antiplatelet (aspirin Clopidigrel)
Thrombolytics (TPA)
Anticoags (Heparin/warfarin)
Indirect thrombin inhibitors (heparin/lovenox)
Direct thrombin inhibitors (dabigatran)
Direct factor X inhibitors (apixaban/rivaroxaban)
Vitamin K antagonists (warfarin)
Clopidigrel
Plavix P2Y12 platelet inhibitor
Contra:
active bleed
Interactions:
Avoid CYP2C19 inhibitors (omeperazole)
Ticagrelor
Brilinta P2Y12 platelet inhibitor
Adverse: Active bleed (fatal)
Warning: Bleed risk
Contra:
History of intracranial hemorrhage
Active bleed
Aggrenox
Combination anti platelet
Interactions:
increased risk of bleeding with anitcoags and anti platelets
Contraindications:
NSAID allergy, asthma, rhinitis, polyps, Viral infections in children (reyes)
Anti coagulant prophylaxis
to prevent or treat DVT, PE, Arterial thromobosis
Heparin
Lovenox
Fondaparinux
Oral anti coagulants for long term use
Coumadin
Dabigatran
Apixaban
Anti coagulants and their factors
LMWH (Xa)
UFH (IIa, Xa)
Warfarin (IIa, VIIa, IXa, Xa)
Direct Thrombin inhibitor (IIA)
Unfractionated heparin
administration
Unfractionated heparin generally is administered intravenously as an initial bolus followed by a continuous infusion using a nomogram.
Subsequent dose adjustments are made based on aPTT or anti-factor Xa activity values
Heparin MOA
Indirect inhibitor of thrombin factor IIa and Xa
Greatly enhances antithrombin to inactivate these
low molecular weight (LMW) heparins
MOA
low molecular weight (LMW) heparins efficiently inactivate factor Xa via antithrombin
Baseline testing prior to administration ofunfractionated heparinor LMW heparin generally includes
coagulation studies (prothrombin time [PT],
activated partial thromboplastin time [aPTT]),
and a complete blood count (CBC)
with platelet count.
Heparin antidote
Protamine sulfate
slow IV infusion
Enoxaparin
Lovenox (LMWH)
Contra:
major bleeding, History of HIT within 100 days,
Warning: Spinal/epidural hematomas
Adverse: Bleeding
fondaparinux
Arixtra
Warning: Spinal/epidural hematomas
Factor Xa inhibitor
Coumadin dosing
Warfarin is monitored by PT/INR
For most patients initiatingwarfarintherapy, we suggest an initial dose of ≤5 mg daily for the first two days rather than higher “loading” doses
We generally use 5 mg for most healthy adults but might use a lower dose (eg, 2.5 mg daily, 5 mg alternating with 2.5 mg) for women older than 70, men older than 80, or those who are frail, malnourished, have liver or kidney disease, heart failure, or are receiving a medication known to increase warfarin sensitivity.
An automated dosing calculator is available atwww.WarfarinDosing.org/Source/Home.aspx.
Dosing on subsequent days is guided by the PT/international normalized ratio (INR) value
Direct thrombin inhibitors
&
Factor Xa blockers
DTI = dabigatran (Pradaxa)
Factor Xa blockers apixaban (eliquis) Rivaroxaban (Xarelto) LMWH (lovenox) UFH (heparin) Vitamin K (Coumadin)
dabigatran
Pradaxa (Direct thrombin inhibitors)
Contra:
active bleeds, mechanical prosthetic heart valve
Warnings:
Spinal/epidural hematomas
premature discontinuation increases thombolytic events
Apixaban
Eliquis (Factor Xa inhibitor)
Contra: active bleeding
Warnings:
Spinal/epidural hematomas
premature discontinuation increases thombolytic events
Coumadin antidote
Vitamin K
Dabigatran antidote
Idaruvizumab
Apixaban
Rivaroxaban
Antidote
PCC
or
Recombinant coagulation factor Xa
(Prothrombin complex concentrate, also known as factor IX complex, is a medication made up of blood clotting factors II, IX, and X)
Prothrombin complex or factor 10
Fibrinolytics MOA
breaks down clots via conversion of plasminogen to plasmin
ITP Treatments
Immune thrombocytopenia (
Glucocorticoids
IVIG
Anti-RhoD
RhoGAM
TTP/HUS Treatment
Emergent plasma exchange if TTP>HUS, eculizumab if HUS>TTP, RBC transfusions, Hemodialysis IVIG Corticosteroids Rituximab Splenectomy
Eculizumab
Soliris
Treatment of atypical hemolytic uremic syndrome (aHUS) to inhibit complement-mediated thrombotic microangiopathy.
Warnings:
Serious meningococcal infections
Pregnancy
Contra:
Unresolved seriousNeisseria meningitidisinfection. Individuals not vaccinated againstNeisseria meningitidis.
If pregnant and exposed call number
Soliris, HUS, No Pregnancy, meningitis or no vaccine
HELLP Treatment
Hemolysis, elevated liver enzymes & low platelet syndrome
Prompt delivery is main goal, IV magnesium sulfate to prevent seizures, anti-hypertensives, blood product transfusions
Delivery, mag, ACE/ARB, blood
Qualitative platelet disorder
Von Williebrands Disease
Von Williebrands Disease Treatment
Hemostatic medications (for bleeding prevention) Desmopressin(DDAVP), Aminocaproic acid, TXA
Replacement therapy (if necessary) vWF concentrate and/or factor VIII concentrate
Pressors, TXA, von willie factor, factor 8
DDAVP (Desmopressin)
Class
Vasopressin (synthetic)
MOA
Stimulates vWF release from endothelium
Hemophilia Treatment
Factor 8 or 9 infusions
Desmopressin, aminocaproic acid, TXA
(no blood thinners, trauma, contact sports)
Vitamin K deficiency treatment
Give vitamin K
DIC treatmtent
correct underlying cause,
FFP or cryoprecipitate transfusion,
platelet transfusion if bleeding predominates,
tissue plasminogen activator (TPA) if clots predominate
AML treatment
Acute Myeloid Leukemia
Chemo
Palliative chemo option = hydroxyurea
ALL
Acute Lymphoid Leukemia
As with AML, treatment is aggressive induction chemotherapy then consolidation +/- bone marrow transplant
Chronic Myelogenous Leukemia (CML)
Treatment
Treatment: tyrosine kinase inhibitors,
which inhibit the bcr-abl oncogene. Examples: imatinib (Gleevec®),
tyrosine kinase inhibitors,
imatinib (Gleevec®),
imatinib (Gleevec®) MOA
Prevents ATP binding
Blocks proliferation and induces apoptosis in Bcr-Abl and Philadelphia chromosomes
Also inhibits tyrosine kinase for platelet derived growth factor
Prevents ATP, TKI ,oncogene
Chronic Lymphocytic Leukemia (CLL/SLL) treatment
Brutons TKI (ie ibrutinib)
Ibrutinib
Imbruvica
Chronic Lymphocytic Leukemia (CLL)
Bruton tyrosine kinase (BTK) inhibitor
BTK for CLL
Hodgkin’s Lymphoma Treatment
ABVD chemotherapy +/- radiation therapy
ABVD Therapy
ABVD
Adriamycin
Bleomycin
Vinblastine
Dacarbazine
Non-Hodgkin’s Lymphoma Treatment
Rituximab, R-CHOP chemotherapy, & radiation
RRCR
CHOP
CHOP
Cyclophosphamide
Hydroxydoxorubicin (doxorubin)
Oncovin (Vincristine)
Prednisone
Multiple myeloma Treatment
Treated with RVD chemotherapy +/- autologous bone marrow transplant +/- palliative radiation or kyphoplasty
RVD therapy
RVD
Revlimid
Velcade
dexamethasone
Myelodysplastic Syndrome Treatments
Observation vs hypomethylating agents (ie azacytidine), immunomodulators (ie lenalidomide),
Which type of hypersensitivity reaction is most associated with an inflammatory process?
I
II
III
IV
IV
Which of the following medications is considered a first-generation histamine (H1) antagonist
fexofenadine (Allegra)
cetirizine (Zyrtec)
diphenhydramine (Benadryl)
desloratadine (Clarinex)
diphenhydramine (Benadryl)
Which of the following systemic glucocorticoids is considered long-acting glucocorticoids?
prednisone (Prednose)
dexamethasone (Decadron)
hydrocortisone (Hytone)
prednisolone (Orapred)
dexamethasone (Decadron)
Which of the following conditions is considered a contraindication for most systemic glucocorticoid medications?
Live vaccinations
Pregnancy (Category X)
Pulmonary embolism
Hypothyroidism
Live vaccinations
Which of the following adverse effects is considered a common effect for patients taking antihistamine (H1 antagonists)?
miosis
excitability in adults
dry mouth
excessive lacrimation
dry mouth
Which treatment of concentrates is sometimes used for the treatment of von Willebrand disease?
factor VII
factor VIII
factor IX
factor X
factor VIII
Which of the following medications is considered the best treatment for chronic lymphocytic leukemia?
cyclophosphamide (Cytoxan)
rituximab (Rituxan)
fludarabine (Fludara)
ibrutinib (Imbruvica)
ibrutinib (Imbruvica)
Which of the following leukemias is usually treated with tyrosine kinase inhibitors such as imatinib (Gleevec)?
Acute lymphocytic leukemia
Chronic lymphocytic leukemia
Chronic myelogenous leukemia
Acute myelogenous leukemia
Chronic myelogenous leukemia
What is the recommended initiating loading dosage for an middle-aged adult patient starting warfarin (Coumadin)?
2 mg PO daily
5 mg PO daily
7.5 mg PO daily
10 mg PO daily
5 mg PO daily
Which of the following treatments is considered a treatment for disseminated intravascular coagulopathy?
clopidogrel (Plavix)
fresh frozen plasma (FFP)
aspirin (ASA)
warfarin (Coumadin)
fresh frozen plasma (FFP)
What is ITP
Immune Thrombocytopenia (ITP)
a condition that causes your immune system to attack your own blood platelets
What is AIHA
Autoimmune Hemolytic Anemia (AIHA),
a condition that leads to the destruction of your own red blood cells
