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Oncology drugs
| Question | Answer |
|---|---|
| What is adjuvant treatment? | Curative treatment after a surgery |
| What is neoadjuvant treatment? | Treatment before a surgery with curative intent |
| Hallmark chemotherapy treatment for NSCLC | Platinum doublets (Cisplatin/Carboplatin + .....) |
| Pemetrexed | Limit BMS by initiating Folic acid, B12, and dexamethasone a week prior to treatment |
| EGFR Antagonists | Erlotinib, Afatinib Cetuximab |
| Erlotinib | Take on an empty stomach (food increases toxicity) DDI with CYP 3A4/1A2 (1A2 is induced by smoking!!); antacids, H2 blockers, PPIs decrease absorption skin toxicity is good--treat like acne 1st line for EGFR mutations! |
| Crizotinib | ALK mutation + NSCLC AE: visual disturbances |
| Bevacizumab | VEGF AE: hemorrhage at site of tumor, HTN, proteinuria, thrombus; add as 3rd agent to cisplatin + paclitaxel |
| Treatment of SCLC | Chemoradiation--chemo then XRT or XRT then chemo; cisplatin + etoposide |
| Stage II Colon Cancer | Surgery --> 5-FU/Leucovorin (maybe add oxaliplatin if high risk) |
| Stage III Colon Cancer | surgery --> FOLFOX 5-FU bolus and overnight + leucovorin + Oxaliplatin |
| Chemotherapy for metastatic colon cancer | FOLFOX + bevacizumab (or cetuximab); FOLFIRI: 5-FU + leucovorin + irinotecan; Irinotecan (single agent) |
| What does 5-FU and Leucovorin together do for treating colon cancer? | leucovorin makes the 5-FU work better; DPD degrades 5-FU, test for deficiency of DPD! |
| 5-FU Continuous infusion vs bolus | Continuous: more mucositis (can be limited with sucking on ice chips), diarrhea, hand&foot syndrome; Bolus: more myelosuppression |
| Other Colon Cancer regimens | Capecitabine (single agent); CapeOX (capecitabine + oxaliplatin) |
| Capecitabine | prodrug of 5-FU; take on full stomach and avoid antacids; AE: think of golf man: phototoxicity, diarrhea, hand&foot syndrome; 5-FU and capecitabine increase warfarin --> use LMWH |
| Oxaliplatin | myelosuppression, moderately emetogenic, much less otoxicity and nephrotoxicity than cisplatin; Peripheral neuropathy exacerbated by the cold |
| Irinotecan | early diarrhea (cholinergic storm) give atropine; late diarrhea give loperamide; metabolized into SN38 |
| Cetuximab | MAB that targets EGFR; mandatory k-RAS testing (patients with k-RAS mutations do not benefit from cetuximab or panitumumab) toxicities: rash (Avoid sun), serious infusion reactions, hypomagnesemia |
| Panitumumab | MAB that targets EGFR; preferred over cetuximab when combined with FOLFOX; toxicities: rash, hypomagnesemia, less infusion reactions |
| Bevacizumab | used in combination with chemotherapy ONLY in metastatic disease; GI perforations when used in colorectal cancers |
| Uses of Tamoxifen | ER+/PR+ breast cancer any stage in pre- or post-menopausal women |
| AE of Tamoxifen | hot flashes/flushing, thromboembolism, endometrial cancer |
| Strong 2D6 inhibitors that must be avoided with Tamoxifen use | Fluoxetine, paroxetine, bupropion |
| Moderate 2D6 inhibitors that shouldn't be taken with Tamoxifen | Duloxetine, sertraline, amiodarone, cimetidine, benadryl |
| Not/minimal 2D6 inhibitors that are safe with Tamoxifen use | citalopram, escitalopram, venlafaxine |
| What Population of women can use Aromatase Inhibitors? | Post-menopausal ONLY |
| What are the AIs? | Anastrazole (1mg qd), Letrozole (2.5mg qd) , Exemestane (25mg qd) |
| AE of AI's | hot flashes, arthralgias/myalgias, loss of BMD |
| Which have a high efficacy AIs or Tamoxifen? | AIs |
| Early stage breast cancer treatment? | Surgery --> local radiation --> hormonal therapy |
| Targeted Breast Cancer Therapy | Trastuzumab for HER2 amplified disease |
| Adjuvant Regimens for Breast Cancer | AC --> T (doxorubicin + cyclophosphamide --> paclitaxel) |
| Trastuzumab | targets HER2; not to be given with anthracyclines, but unlike anthracyclines the HF it causes is transient and reversible |
| 1st line for prostate cancer therapy | androgen deprivation therapy--medical castration; GnRH agonists, GnRH antagonists, antiandrogens; testosterone < 50 |
| GnRH agonists **DO NOT D/C these | Leuprolide, Triptorelin, Goserelin, Histrelin |
| What happens during the first couple weeks of therapy with a GnRH agonist? | Tumor flare! Consider 1-2 weeks of antiandrogen therapy |
| AE of GnRH agonists | hot flashes, ED, decreased libido, bone pain (if bone mets) |
| Antiandrogen | Bicalutamide, Enzalutmide; AE: hot flashes, decreased libido |
| Bicalutamide | 50mg qd; AE: diarrhea, hematuria |
| Enzalutamide | 160mg qd; AE: seizures, CNS effects, HA |
| ADT consequences | Decreased BMD, metabolic syndrome, DM, CAD |
| What do you give men with prostate cancer and bone mets? | Bisphosphonates + calcium and vitamin D supplementation; monitor SCr |
| Denosumab | Treatment of ADT-induced bone loss and prevention of SREs |
| Abiraterone | CYP17 inhibitor; TAKE ON EMPTY STOMACH (food increases AUC 10x) AE: mineralocorticoid excess (HTN, hypokalemia, edema) must take in combo with prednisone |
| Androgen Independent Prostate Cancer | Docetaxel + Prednisone; AE: myelosuppression, edema, peripheral neuropathy |
| Localized Prostate Cancer | Radiation + Prostatectomy often curative |
| Vemurafenib | BRAFV600E (for mutation only) used in metastatic melanoma; increased risk of new skin cancer--frequent dermatologic evaluation |
| Dabrafenib | BRAF TKI; high-fat meal will DECREASE absorption; insoluble at pH > 4 |
| CTLA-4 | "brake pedal" to immune system--block this for more activity against tumor cells |
| PD-1 | prevents immune response to activating; block this and we can make immune system more effective at fighting tumor cells |
| Ipilimumab | CTLA-4 inhibitor; BBW for immune-mediated response (entercolitis, hepatitis, dermatitis, neuropathy, endocrinopathy) treat with high dose corticosteroids and D/C until symptoms return to baseline and pred dose <7.5 |
| Pembrolizumab and Nivolumab | PD-1 inhibitors; immune-related toxicities |
| Dual Therapy in Metastatic Myeloma | blocking multiple pathways is better, but still leads to inevitable resistance and greater toxicity |
| Asparaginase | Usually part of the induction process for ALL; AE: hypersensitivity reactions, pancreatitis, hyperglycemia, coagulopathies (clots and bleeding) |
| Induction chemotherapy in ALL | Kill everything, leukemia cells and bone marrow cells |
| Consolidation and Intensification chemotherapy in ALL | eradicated leukemia cells; most regimens include high dose MTX |
| Maintenance chemotherapy in ALL | daily 6-MP taken at NIGHT; if TPMT deficient reduce dose; avoid milk and allopurinol; OR weekly MTX therapy; OR monthly vincristine + corticosteroid blast |
| Risks of ALL treatment | Induction phase: TLS (prevention with NS and allopurinol) infection risk (FN) |
| Induction Chemo for AML | 7 days Cytarabine (cont. infusion) + 3 days anthracycline |
| Consolidation Chemo for AML | HiDAC (high dose Ara-C--cytarabine) unique toxicities: cerebellar dysfunction, chemical conjunctivitis (corticosteroid eye drops) |
| Which antibiotic should not be chosen as a prophylactic drug for infectious complications in during leukemia chemotherapy? | Bactrim--causes additional myelosuppression! |
| During which stage of AML therapy should you avoid the use of growth factors? | Induction stage; during consolidation you can use growth factors; In ALL, there is no concern with growth factor use |
| When should you begin treatment for CLL? | Only when needed; symtomatic, spleno/hepatomegaly, infectious complication, autoimmune complications |
| What are treatment option for CLL? | Any combination of fludarabine, cyclophosphamide, rituximab; bendamustine (alkylating agent) |
| Rituximab | Anti-CD20 MAB; Toxicities: infusion reactions (pretreat with APAP and benadryl) |
| Follicular (indolent) NHL | localized disease; curable with radiation therapy alone |
| Advanced NHL | radiation, chemotherapy (RCHOP/R-bendamustine), radioimmunotherapy |
| Aggressive (Diffuse Large B-cell Lymphoma) | RCHOP = rituximab + cyclophosphamide + doxorubicin + vincristine + prednisone |
| Very Aggressive (Burkitt's Lymphomas) | alternate between A cycle and B cycle (resistance) with Rituximab throughout; A cycle = HyperCVAD (hyper-fractionated cyclophosphamide + vincristine + doxorubicin + dexamethasone); B cycle = high dose MTX, high dose cytarabine |
| Hodgkin's Lymphoma | radiation + combination chemotherapy; late toxicities: leukemias, CV disease, pulm disease, solid tumors (in radiation field) |
| Chemotherapy for Hodgkin's | ABVD = doxorubicin + bleomycin + vinblastine + dacarbazine (all agents given on days 1 & 15) NO dose delays or G-CSF regardless of low counts! |
| Multiple Myeloma Presentation | C = hypercalcemia R = renal dysfunction A = anemia B = bone fractures |
| MM Treatment | autologous stem cell transplant; chemotherapy for non-transplant candidates (melphalan + prednisone) |
| Melphalan | alkylating agent only used in MM; harvest stem cells, kill all cells with melphalan, rescue with stem cells |
| Thalidomide | AE: peripheral neuropathies, somnolence, neutropenia; thrombosis prophylaxis (ASA) |
| Lenalidomide | AE: neutropenia; thrombosis prophylaxis (ASA) |
| Pomalidomide | used after lenalidomide failure |
| Bortezomib | proteasome inhibitor; AE: sensory neuropathy; Interaction with Green tea! |
| Treatment approach for CML | first line TKI--imatinib, dasatinib, nilotinib; Allo HSCT if TKI failure |
| Imatinib | BCR-ABL is the only issue with CML; Imatinib blocks BCR-ABL; Imatinib > combo therapy; resistance is NOT inevitable; 3A4 substrate; increase synthroid doses; take with food to minimize AE |
| Dasatinib | blocks BCR-ABL; AE: pleural effusion; interaction with PPIs |
| Nilotinib | active in most imatinib-resistant BCR-ABL mutations; AE: QT prolongation; take on empty stomach |
| CML and adherence | Adherence is very important as this is a chronic disease! |
| GVHD Prophylaxis Regimen | MTX + Tacrolimus |
| Calcineurin Inhibitors | Cyclosporine, Tacrolimus; both limited by nephrotoxicity and metabolized by CYP3A4; nonmodified and modified cyclosporine formulations not interchangeable |
| Cyclosporine AE | nephrotoxicity, HTN, tremor, hyperlipidemia, hypertriglyceridemia, gingival hyperplasia, hirsutism |
| Tacrolimus AE | nephrotoxicity, HTN, tremor, hyperglycemia, HA (dose dependent), electrolytes abnormalities (hyperk, hypomag, hypophos) |
| Mycophenolate Mofetil | stable in acidic environments (unlike MPA); first pass converts MFF --> MPA; AE: diarrhea |
| mTOR Inhibitors | Sirolimus (macrolide); AE: myelosuppression, delayed wound healing, hypercholest and hypertriglyc, mouth ulcers |
| Treatment of acute GVHD | methylprednisolone 1-2mg/kg/day |
| Induction therapy for solid organ transplant | Methylprednisone, antimetabolite, calcineurin inhibitor (best), antibody therapy |
| Antibody therapies **these are all immunosuppressive** | OKT-3 (muromonab-CD3), daclizumab and basiliximab, alemtuzumab; polyclonal: anti-thymocyte globulin |
| Antithymocyte Globlin | comes from animals rabbit (RATG--thymoglobulin) preferred in kidney transplants;equine (atgam) preferred in aplastic anemia |
| Antithymocyte globulin safety | myelosuppression (dose limiting) |
| Treatment of acute organ rejection | increase immunosuppression (increase dose or add another agent); pulse corticosteroids |
| cell-cycle specific agents | antimetabolites, vinca alkaloids, taxanes, etoposide, irinotecan, topotecan |
| cell-cycle nonspecific agents | anthracyclines, platinums, alkylating agents, dacarbazine, nitrosureas (carmustine) |
| targeted agents | MABs, hormonal (tamoxifen and AIs), TKIs (EGFR, VEGF, HER2, BCR-ABL) |
| Antimetabolites | MTX, cytarabine, 5-FU, gemcitabine, fludarabine, 6-MP, hydroxyurea |
| Vinca alkaloids | Vincristine, Vinblastine, Vinorelbine |
| Taxanes | Paclitaxel, Docetaxel |
| Anthracyclines | doxorubicin, daunorubicin, idarubicin, epirubicin |
| platinums | cisplatin, carboplatin, oxaliplatin |
| Alkylating agents | cyclophosphamide, ifosfamide, melphalan, busulfan, chlorambucil; cause secondary leukemia, teratogenic |
| Cyclophosphamide | Prodrug activated in liver (2B6, 3A4/5) inducers increase toxicity; prevention of hemorrhagic cystitis in high doses ( bone marrow transplants) with fluids and mesna |
| Ifosfamide | Prodrug activated in liver (2B6, 3A4/5) inducers increase toxicity; hemorrhagic more likely to occur--must give fluids and mesna ALWAYS! |
| Nitrosureas | Carmustine, Lomustine; very lipophilic (cross BBB) |
| Dacarbazine | prodrug metabolized to active MTIC (1A2) |
| Temozolomide | prodrug chemically degraded to MTIC; 100% bioavailable |
| Cisplatin | HIGHLY EMETOGENIC; nephrotoxic (give fluid before and after--add electrolytes), ototoxicity, neuropathies, electrolytes abnormalities (hypok, hypomag), minimal BMS |
| Carboplatin | dosed based on renal function (calvert equation); toxicity: BMS |
| Oxaliplatin | neuropathies exacerbated by cold temperatures |
| Doxorubicin | red urine |
| Anthracycline Toxicities | myelosuppression, irreversible cardiotoxicities (MUGA at baseline) |
| Mitoxantrone | not an anthracycline (but close); NO free radical production (less cardiotoxicity than anthracyclines) |
| Taxane administration | every 3 wks: more myelosuppression; every week: more neuropathy, nail changes |
| Paclitaxel | hypersensitivity reactions due to vehicle (cremphor) premed with dex, benadryl, and H2 blocker |
| Docetaxel | causes edema that must be pretreated with dex for 3 days (start prior to treatment) |
| What class of drugs are FATAL if given intrathecally? | Vinca alkloids |
| Which vinca alkaloid does not cause myelosuppression? | Vincristine |
| Cytarabine (Ara-C) | standard doses cause myelosuppression and mucositis; high doses cause cerebellar toxicity and chemical conjunctivitis (corticosteroid eye drops) |
| 6-MP | coadministration with xanthine oxidase inhibitors increases toxicity |
| Fludarabine (purine analog) | risk of opportunistic infections (AIDS-like), PCP prophylaxis (bactrim, inhaled pentamidine), HSV, VZV prophylaxis |
| MTX | hydration and alkalinization of urine can prevent renal failure |
| High dose MTX therapy | Leucovorin rescue; avoid drugs that may delay clearance: probenacid, sulfamethoxazole, penicillins, NSAIDs/ASA |
| Drugs that cause secondary leukemias | etoposide, anthracyclines, alkylating agents |
| Bleomycin toxicity | pulmonary fibrosis |
Created by:
simpsonan
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