Pharm 2 exam 3

Normal vs Cancer cell (4 for each)

Normal

• Large cytoplasm

• Single nucleus

• Single nucleolus

• Fine chromatin

Cancer

• SMALL cytoplasm

• Multiple nuceli

• Multiple & large nucleoli

• Coarse chromatin

Cancer RF (9)

1. Age

2. Genetics→ inherited

3. Bacteria & Viruses (H. pylori, Hep B or C, HPV, vaccines)

4. Diet, obesity, activity levels

5. Stress

6. Smoking

7. Radiation (ionizing & UV)

8. Exposure to carcinogens

9. Alcohol ingestion

Cancer GOALS-4 & TX Options-3

Goals

• Cure

• Prevent metastasis

• Palliative care

• Maintain quality of life

Treatment Options

• Surgery (resection)

• Radiation→ primary tx

• Chemotherapy

Toxicity of Antineoplastic (aka Cancer Drugs) (6)

1. Hard to kill cancer cells without also affecting normal cells

2. Normal cells that replicate & divide quickly are the ones most likely to get damaged:

3. These include your: skin, GI tract, bone marrow (high growth factors)

4. EX→ when hair follicles are damaged it causes Alopecia (hair loss)

5. EX→ when GI tract is damaged it can cause mouth sores (mucositis), difficulty swallowing, infections, diarrhea

6. Tip- use a soft tooth brush & avoid mouthwash bc of alcohol base irritability

Toxicity of Antineoplastic (cancer drugs); can lead to what-3, A.E-1, Contraindication-1, +3 more things, HELP/counter effect-2

• Antineoplastics may damage stem cells leading to→ anemia (low rbc), leukopenia (low wbc- infection risk!) , thrombocytopenia (low platelets- bleeding risk)

• A.E are DOSE LIMITING→ meaning doctors can’t inc dose too much or it becomes harmful but they can stop if cell counts are too low

• Contraindication- severe/low bone marrow depression

• Every antineoplastic has a NADIR (lowest point to which RBC, WBC, platelet count drops to bc of drug)

• Neutropenia (dec WBC) = below 1500

• Neutropenia precautions- protect pt from infection, limit visitors

• Medications that HELP/ counter effect of Antineoplastics/ Help bone marrow recover: Epoetin Alfa for RBC & Filgrastim for WBC (neutrophils)

Neutropenic Precautions; pt teaching-6 & nurse responsiblities-5

Pt teaching

• Watch your diet

• Limit your exposure to germs + proper hand washing

• Wear a mask in public

• Pay attention to your skin

• Get enough rest

• Seek medical help IMMEDIATELY for a Fever = can mean infection!

Nurse responsibility

• Contact precaution in reverse

• Private room + aseptic technique

• Limit visitors

• Admin meds as ordered

• NO fresh flowers or fruit

Chemotherapy Associated Drugs- help bone marrow recover after chemotherapy; med, use, MOA, route, A.E-4

Med→ Epoetin Alfa

• Use→ to treat chemo-associated Anemia (LOW RBCs)

• MOA→ stimulates RBC production in bone marrow

• Route→ SQ injection

• A.E→ MI, Stroke, Thromboembolism-blood clots, Tumor progression/ recurrence

Chemotherapy Associated Drugshelp bone marrow recover after chemotherapy (pt2); med, use, MOA, route, A.E-2!

Med→ Filgrastim

• Use→ to treat chemo-associated NEUTROPENIA (LOW WBCs)

• MOA→ stimulates production of granulocytes in bone marrow

• Route→ SQ injection

• A.E→ Thrombocytopenia→low PLATELET count, Splenomegaly→enlarged spleen

MORE toxicity of Antineoplastics (cancer drugs); side effects (2) and their treatments/ prevention + other s.e-2

• Vomiting center in medulla is triggered by Antineoplastics (n/v)

• TX→ eat small frequent meals, do NOT lie down, AVOID strong smelling food, use cold fluids for ulcers

• Pt can be premedicated w Antiemetic like ondansetron (zonfran) prior to tx

• Antineoplastics are also Vesicants= can cause serious tissue damage if it escapes from vein during infusion(extravasation)

• To prevent it→ use a central line, & an infusion pump ONLY

• Other S.E→ Fatigue, Infertility!

4 Pharmacotherapy Administration Routes

1. Oral

2. Direct Instillation

3. Intravenously (most drugs)

4. Intrathecal - injected into spinal fluid

Alkylating Agents; med-1, MOA-3, use-1, routes-2

Med → Cyclophosphamide

MOA

• Forms bond/ link with DNA in the cancer cell (process called alkylation)

• Changes shape of DNA to double helix→ which prevents nucleic acid from completing normal cell division & dividing

• Kills cancer cells in ALL phases of cell cycle

• Use→ treats a WIDE variety of cancers

• Routes → PO- give on EMPTY stomach for best absorption or IV- caution bc severe vesicant!

Alkylating Agents; A.E- 4, patient education-2, interactions- 6

A.E

• Hemorrhagic cystitis- bleeding due to severe bladder inflammation

TX- Cytoprotectant for bladder→ Mensna

• Cardiomyopathy in high doses

• SIADH (water retention= hyponatremia ) in high doses

• Pigmentation/ darkening of skin or nail beds

Patient Education

• Void before dose & increase fluid intake

• Teratogenic! - NO in pregnancy !

AVOID!

• Doxorubicin can potentiate cardiac toxicity! *caution

• Interaction w herbal productions→ garlic, ginkgo, ginseng, echinacea, st. john’s wort

Mneumonic for Alkylating Agent; Bladder

BLADDER

B- bleeding bladder (hemorrhagic cystitis, give mesna)

L- low sodium + water retention (SIADH) 

A- avoid in pregnancy (teratogen)

D- drink fluids + void before dose

D- darkening/ pigmentation of skin & nails

E- eval interactions → garlic, ginkgo, ginseng, echinacea, st. john’s wort

R- risk with doxorubicin = cardiac toxicity

Antimetabolites (overview of what they do); diff types-3

• Rapidly growing cancer cells need nutrients to make proteins

• Antimetabolites look structurally similar to those proteins but do NOT perform/ function the same (they are a fake versions)

• Cancer cell takes in this fake version (antimetabolites) = which stops/tricks them from growing so they die

• There are different types of Antimetabolites (fake nutrients) such as: Folic acid analogs, Purine analogs, Pyrimidine analogs

Antimetabolites; med, MOA-2, uses-3, routes-3

Med → Methotrexate

MOA → Blocks synthesis of folic acid during S phase of cancer cell (S phase- when the cell is making DNA)

• Without folic acid- cell can’t copy DNA→ so it can’t grow or divide

• Other Uses→RA, psoriasis, ectopic pregnancies (in smaller doses)

• Routes→ PO- can take with or without food, IM or IV- incompatible w many medications + administer thru dedicated line (its own IV line)

Antimetabolites; A.E-5, Pt teaching-4, interactions-6

A.E

• Fatal bone marrow toxicity (stops body from making RBC, WBC, platelets); Antidote→ Leucovorin

• Ulcers & GI bleeding

• Hepatotoxicity (Liver- Monitor AST, ALT) *LFTs

• Pulmonary fibrosis- lung damage

• Teratogen (Avoid in pregnancy for at least 6m after treatment; category X) *goes for both women & men!

Patient Education

• soft tooth brush, contraceptives, no alcohol, report bleeding

Interactions

• NSAIDS (ibuprofen), Salicylates (aspirin), Sulfonamides inc risk of methotrexate toxicity

• Alcohol use will inc risk of hepatotoxicity (avoid!)

• Caution w herbals- ginseng & st john’s wort

Mneumonic

M – Mouth & GI problems → mouth ulcers, GI bleeding → use soft toothbrush, report sores

E – Eliminate toxins carefully → bone marrow suppression can be fatal → leucovorin is the rescue drug

T – Toxic to liver & lungs → monitor for hepatotoxicity and pulmonary fibrosis; avoid alcohol

H – Halt pregnancy → Category X → avoid pregnancy during and 6 months after treatment

O – Other meds & herbs interact → NSAIDs, aspirin, sulfa drugs ↑ toxicity; avoid ginseng & St. John’s wort

Antitumor Antibiotics; med, MOA-3, routes-2, reminder-1

Med → Doxorubicin

MOA→ made from Natural Antibiotics but do NOT treat infections (just cancer)

• Bind to DNA & change function/shape like Alkylating Agents

• Block/bind to enzymes that normally repair DNA (making it harder for cancer cell to survive)

• Routes→ IV or liposome injectable form

• REMINDER→ Doxorubicin can cause cardiac toxicity in Alkylating Agents!

Antitumor Antibiotics; S.E-2, A.E-5

Side Effects (BOTH REVERSIBLE & Expected)

• Alopecia

• Red urine/ tears (lasts 1-2days after infusion)

A.E!

• Cardiotoxicity, CHF

• Cytoprotectant→ Dexrazoxane, given w Doxorubicin to dec risk of cardiotoxicity

• Severe myelosuppression (dec leukocytes/WBC) - inc risk of infection; NADIR (lowest count) happens 10-14day after a dose

• Superinfections (since its an antibiotic it disrupts normal flora - leading to secondary infections)

• Teratogenic! + Found in Breastmilk so NO breastfeeding/ pregnancy

Plant Alkaloids; Med + derived from, MOA, overview-2, Route-1 + antidote

Med→ Vincristine

(derived from Periwinkle Plant)

• Come from plants that naturally contain substances able to fight cancer

• Stop cancer cells from dividing- so tumor can’t grow

• MOA→ inhibit mitosis of cancer cells in M phase!

• Routes→ IV ONLY- vesicant; Antidote→ Hyaluronide

Plant Alkaloids; S.E-3, A.E-3

S.E

• Peripheral neuropathy- numbness. tingling

• Check DTR (dec dose if worsens)

• Constipation (more common in kids)

A.E

• NEUROtoxicity → sensory loss, difficulty walking, HYPOreflexia, muscle wasting

• Neurotoxicity is dose-limiting- determines how much can be given

• Cytoprotectant→ Leucovorin

• Teratogen!- avoid in pregancy

Hormones & Hormone Antagonist: Med, overview-1, MOA-2, route-1

Med → Tamoxifen

• Not true chemotherapy; but still used to treat certain cancers dependent on hormone growth

• MOA→ act like a mask, block the cancer cell & prevent them from using or producing hormones

• Tamoxifen is a SERM (selective estrogen receptor modulator) → blocks estrogen receptors on ER+ breast cancer (estrogen recep positive)

• Route→ PO

Hormones & Hormone Antagonist; benefits-2, S.E-3. A.E- 2, patient teaching-2

Benefits

• Maintain bone density (prevent osteo.)

• Inc HDL (good cholestrol)

S.E

• N/V

• Hot flashes

• Blurred vision

A.E

• Thromboembolism (blood clots)

• Endometrial hyperplasia- uterine cancer risk

Patient Teaching

• Regular eye exams bc vision S.E

• Report→ leg pain/ swelling, sudden chest pain, SOB, abnormal vaginal bleeding/ spotting- thick uterine lining

Principles of Immunosuppression (w organ trasnplant); 2 overview + 2 after transplant

• Biggest challenge after a transplant is the immune system — it naturally wants to attack the new organ bc it sees it as foreign (not part of the body)

• To prevent rejection, patients are given immunosuppressant drugs — these medicines weaken parts of the immune system so it doesn’t attack the transplanted organ

After Transplant

1. Induction therapy: intensive/ short immunosuppression right after transplant to help body accept new organ

2. Maintenance therapy: lifelong immunosuppression to keep the organ functioning & prevent rejection over time

Calcineurin Inhibitors; Med, MOA, S.E-7, warning-1, Interaction-1, Monitor-3, Risk-1, pt teaching-1

Med → Cyclosporine

• MOA→ inhibit calcineurin phosphate (ultimately inhibiting T lymphocyte proliferation → prevent organ rejection after transplant)

S.E

1. GI distress

2. HTN

3. HA

4. Gingival hyperplasia

5. Hirsutism - inc hair growth

6. Paresthesia

7. Tremor

BBW→ serious infections & malignancies

Interactions → Grapefruit increases blood concentration (toxicity risk)

Monitor → Therapeutic drug levels, kidney-BUN & creatinine, & Liver- LFT → AST & ALT (nephrotoxicity & hepatotoxicity)

• Can inc risk for prematurity, NOT safe while breastfeeding (teratogen)

• Pt teaching → NO live vaccines