Pharm oncology Flashcards
4 Pillars of cancer tx
SRCI
- Surgery
- Radiation
- Chemotherapy
- Immunotherapy
Cancer treatment timeline
broad
Surgery
* galen-> breast cancer
* Mastectomies 1800s
* Exploratory surgeries 1900s
* Now robotics
Radiation
* Roentgen->new kind of ray
* Early docs gave themselves Radiation to determine dose
* now= CRT- Conformal Radiation therapy
Chemo
* ww2 nitrogen mustard gas exposure
* Aminopterin- MTX precursor- ALL tx
* Devita and Cannellos for MOPP- 1st combo chemo cured Hodgkins
* Now-> targeted therapies
Chemo basics
rarely singel
- Cycles and days are numbered (cycle 3 day 8)
- Setting and intent matter
- No side effect free regimens-> management of AEs have drastically improved
* N/V most feared
* Myelosuppression most common
* alopecia= not all chemo
* oral therapies are not necessarily less than IV chemo
types of settings and intent for chemo
- Neoadjuvant vs Adjuvant (before or after surgery)
- curative vs palliative
- first line vs second or third
- Dose dense (more often) vs Dose intense (give more)
Antineoplastic man
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CTCAE
common terminology criteria for adverse events
standards for description and safety info for oncology practice and research: Very Bad, Significant, or profound anemia means different things
Chemo Induced Nausea/Vomiting (CINV)
antiemetic guidelines
how likely a chemo drug is to cause N/V
Causes CINV
Cisplatin
Class Ankylating agents/Platinums
MOA: inhibits DNA synth by the formation of DNA cross-liks (NONSPECIFIC)
Uses: Many- lung, head, neck, pancreatic, ovarian
AE: CINV, peripheral neuropathy, myelosuppresion, NEPHROTOXIC, OTOTOXIC
Monitoring: CBC, CMP, audiometric @ baseline, neuro exam
Types of Emesis and Prevention of CINV
- Acute emesis- 1-2 hours after for 4-6 hours
- Delayed emesis- after 24 hours
- Anticipatory emesis- prior to tx due to conditioned response
Receive Pre-Medications for CINV + rescue meds
Classes of antiemetics for CINV
1 of each is given
- 5-HT3 Receptor antagonists (ondansetron)- QTc prolongation
- Neurokinin-1 receptor antagonists (best for delayed N/V)- CYP3A4 inhibitor
- Additional options- Glucocorticosteroids, Lorazepam
Chemo Induced Diarrhea- Mech, ddx, tx
Mechanism:
* secretory: high secretion of electrolytes due to low absorp (epithelial damage)
* Osmotic: increased intraluminal osmotic substance
* Altered GI motility
DDX: Infectious causes-e. coli, fat malabsorption-pancreatic ca, Neutropenic enterocolitis- guts infection
TX:
mild: loperamide/imodium
Severe: Octreotide
All: bland diet, hydration
Irinotecan/Camptosar, CPT-11
class: plant alkaloid
MOA: Topoisomerase 1 Inhibitor (S&G2 phase)
Uses: Colon and pancreatic
AE: Diarrhea imm and delayed, CINV, Neutropenia, Fatigue
Monitoring: CBC, CMP, Mag, Phos
Chemo induced myelosuppression (most common se)
Most common dose limiting AE-> 1 or more cell lines can be effected-> dose reductions and delays= management
General Management:
Prevent: growth factors-> for neutropenia, Prophylactic antibiotics for prolonged neutropenia
TX: platelet and RBC transfusion
Dose dense AC (ddAC+T) for HER2- Breast cancer
Doxorubicin (adriamycin): Anthracycline
Cyclophosphamide: Alklating agen
MOA:
* Doxorubicin: Intercalation btwn DNA base pairs by inhibition of topoisomerase 2 and steric obstruction (multiple phases of the cell cycle)
* cross linking DNA strands and decreasing DNA synth (cell cycle non specific)
Uses:
Neoadjuvant chemo for Stage 3 Her 2= shrink tumors for surgeon
AC(ddAC)= Cycle length, AE, Monitoring
Cycle:
on Day 1 of each 14 day cycle-> for 4 cycles
+ weekly Taxol for 12 cycles
AE: Neutropenia, CINV, infusion site rxn (doxorubicin is vesicant= skin eating), cardiotoxicity low LF
Monitoring: CBC, CMP, Echo before at completion and 6 months post bc doxo-> cardio
AC(ddAC)= Cycle length, AE, Monitoring
Cycle:
on Day 1 of each 14 day cycle-> for 4 cycles
+ weekly Taxol for 12 cycles
AE: Neutropenia, CINV, infusion site rxn (doxorubicin is vesicant= skin eating), cardiotoxicity low LF
Monitoring: CBC, CMP, Echo before at completion and 6 months post bc doxo-> cardio
Chemo induced neutropenia- meaning, tx, risk of neut fever
Neutropenia= ANC<1500
Severe= ANC<500
Control measures: Hand hygiene, no flowers, no rectal thermometer
G-CSF Prophylaxis for those in risk of fever or neutropenia is greater than 20 percent
Chemo regimen + patient factors= risk of neut fever
* 65 yr old and older
* previous chemo
* open wounds or surgery
* multiple comorbid conditions
* HIV
G-CSF->Granulocyte colony stimulating factors: EX, MOA, dosage, AE, Monitoring
prevent neutropenia
Ex: Filgrastim, Pegfilgrastim
MOA: binds to hematopoietic cell receptors and stim production, maturation, and activation of neutrophils
Dosage: IV or on body injector
AE: BONE PAIN = LORATADINE b4 and after to prevent, NSAIDS for pain. Leukocytosis
Monitoring: CBC, fever curves
Febrile Neutropenia definition and groups
Def: single oral temperature of 101 F or 100.4 for more than 1 hour
Cause: 20-30% of cases = translocation of endogenous bacteria- Gram+
what to KNOW: when chemo, what regimen, ANC-> blood culture 1st+ IV Abx w/in 60 min then imaging, UA, lactic acid, Procalcitonin
Groups:
High risk: 95%
* Severe Neutropenia for more than 7 days
* severe comorbidities
* renal or hepatic dysfunciton
ADMIT AND IV ANTIBIOTICS
Low risk: 5%
* receiving OP (outpatient) chemo
* no comorbidities
* good performance status
* expected to recover counts quickly
* youth
OP tx w/ oral fluoroquinolone plus amoxicillin
Rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone (R-CHOP) classes
Rituximab/Rituxan: Monoclonal anti-CD20
Cyclophosphamide: Alkylating agent
Doxorubicin/Adriamycin: Athracycline
Vincristine/Oncovin: Vinca alkaloid
Prednisone: Glucocorticoid
R-CHOP, uses, cycle, AE
Uses: Aggressive Non Hodgkins lymphomas
Cycle: 21 days except prednisone on day 1-4
AE: Myelosuppression-> severe nuetropenia >20%, infusion rxn (rituxan), neuropathy(vincristine), cardiotoxicity
Cardiotoxicity of chemodrugs basics+common agents
Complications:
* Arrhythmias
* heart failure
* myocardial necrosis->dilated cardiomyopathy
* Vasospasm or vasoocclusion-> angina or MI
* pericardial disease
* arterial occlusive events
common agents:
* anthracyclines
* Fluoropyrimidines
* HER2 targeted therapies
Cardiotoxic drug classes
- Anthracyclines
* doxorubican, heme malignancies, ROS mediated decreased LVEF, LIFETIME DOSE LIMIT - Fluoropyrimidines
* Fluorouracil, GI cancers, CORONARY SPASM, access risk factors - HER2-targeted therapies
* Trastuzumab, HER2+ breast/colon/gastric, Asympt decrease LVEF, Echo q3 plus q6 for 2 years after
Chemo induced Peripheral Neuropathy (CIPN) common
PROFOUND IMPACT ON QUALITY OF LIFE
Colon (Oxaliplatin)
Breast (Taxanes)
* one of the mc reasons chemo dose is reduced
other cures, cyrotherapy, compression, exercise, duloxetine-> may treat…..but lack data
