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