Hem/Onc Exam 3

A 32 year-old kidney transplant patient is receiving cyclosporine 75 mg IV daily while hospitalized and unable to take any medications by mouth. The patient is now able to tolerate oral medications, and the transplant physician asks you, the transplant pharmacist, to calculate the equivalent total daily dose of oral cyclosporine. Which of the following is the most appropriate oral cyclosporine dose?

225 mg PO daily (IV:PO = I:3)

In a clinical trial testing a new cancer treatment, “progression-free survival” (PFS) is often measured. Which of the following examples best represents progression-free survival?

a patient with breast cancer receives chemotherapy. After one year, their cancer has NOT worsened, and they are still alive

A 34 year old male presents to the emergency department with fever, fatigue, weight loss, and persistent diarrhea. He reports engaging in high-risk sexual behaviors and has not had recent medical follow-ups. The physician suspects HIV infection. Lab results are pending. What is the most appropriate methods to diagnose HIV infection in this patient?

HIV p24 antigen and HIV-1/2 antibodies (fourth generation test)

A 28 year old male presents to the emergency department following a needlestick injury at work. He reports that the patient whose blood he was exposed to is HIV-positive but currently on ART with an undetectable viral load. The incident occurred approximately 2 hrs ago. The patient has no significant past medical history. When is the most appropriate time to start post-exposure prophylaxis (PEP) for this patient?

immediately within 72 hrs of exposure

A 42 year-old male with a history of HIV presents with fever, weight loss, and cough. He has been non-compliant with his antiretroviral therapy (ART) and his CD4 count is 50 cells/uL. A chest x-ray shows diffuse infiltrates. Lab results are pending. Which opportunistic infection (OI) is most likely responsible for this patient’s symptoms, and when is it most commonly seen in HIV patients?

Pneumocystis pneumonia (PJP), CD4<200 cells/uL

Which of the following is a key advantage of using overall survival (OS) as an endpoint in cancer clinical trials?

it provides an objective measures, as it is easy to define and track without bias

A 42 year old male with HIV and a CD4 count of 150 cell/uL presents with a fever, cough, and shortness of breath. Chest X-ray reveals bilateral diffuse infiltrates. The patient reports not being on any prophylactic medication for opportunistic infections. Lab tests confirm a diagnosis of PJP. Which of the following is the most appropriate initial treatment for this patient’s PJP?

Trimethoprim-sulfamethoxazole (TMP-SMX) with corticosteroids if PaO2 <70 mmHg

Based on the figure above showing relative and absolute survival rates over five years for colon cancer patients of different age groups, which of the following statements is true?

Both the relative and absolute survival rates decrease more sharply over time for individuals aged 80+ compared to younger age groups

A 40 year old kidney transplant recipient is taking sirolimus as part of their immunosuppressive regimen. The patient is scheduled to undergo elective abdominal surgery next week. During the preoperative medication review, the pharmacist notices that the patient is still taking sirolimus. Which of the following is the most appropriate recommendation?

Discuss temporarily holding sirolimus with the transplant team and restarting therapy once adequate wound healing has occurred

In a study of hormone replacement therapy (HRT), 500 out of 20,114 non-users and 52 out of 1612 uses of combined HRT developed breast cancer, as depicted in the table below

What is the risk difference between groups?

0.75%

Mrs. Jones is a 48 year old F who received a decreased donor kidney transplant (DDRT) 3 months ago. She has had a relatively uncomplicated post-transplant course. Her maintenance immunosuppression regimen consists of tacrolimus 2 mg BID, Myfortic 720 mg BID, and prednisone 5 mg daily. Her insurance coverage has changed recently, and she is required to switch from Myfortic to Cellcept per her insurance plan. What is the equivalent dose of Cellcept for Mrs. Jones?

1000 mg BID

A 28 year old male presents to the clinic seeking advice on how to protect himself from HIV. He reports being sexually active with multiple male partners and inconsistently using condoms. He has no known history of sexually transmitted infections and is otherwise healthy. Which of the following interventions would be most appropriate to reduce this patient’s risk of acquiring HIV?

Start daily pre-exposure prophylaxis (PrEP) and discuss the importance of regular HIV testing

In oncology clinical trials, censoring is often used when analyzing patient survival data. Which of the following best describes the concept of censoring?

patients who leave the study early, or whose survival time is unknown by the study’s conclusion, are accounted for

Match the HIV antiviral to characteristic/mechanism: boxed warning for hypersensitivity with HLA-B*5701

abacavir

Match the HIV antiviral to characteristic/mechanism: boxed warning for reactivation of HBV

tenofovir alafenamide

Match the HIV antiviral to characteristic/mechanism: NNRTI that must be taken on empty stomach preferably before bedtime

efavirenz

Match the HIV antiviral to characteristic/mechanism: pharmacokinetic enhancer

cobicistat

Match the HIV antiviral to characteristic/mechanism: HIV tropism must be evaluated prior to use

maraviroc

Match the HIV antiviral to characteristic/mechanism: HIV capsid inhibitor

lenacapavir

Match the HIV antiviral to characteristic/mechanism: CD4-post attachment inhibitor

ibalizumab-uiyk

A 42 year old male with HIV present to clinic for routine follow-up. He reports intermittent fatigue and dizziness. His antiretroviral therapy (ART) includes tenofovir alafenamide, emtricitabine, and dolutegravir. Lab results are as follows:

• CD4 count 550 cells/mm³

• Viral load: undecetable

• Hemoglobin = 10.5

• MCV = 110

• Vitamin B12 = low

What is the most appropriate intervention to optimize care for this patient?

start vitamin B12 supplementation

Is sickle cell anemia a homozygous or heterozygous?

homozoygous

What is exclusively made in sickle cell anemia?

HgbS

What is the lifespan of a normal RBC?

90-120 days

What is the lifespan of a sickle cell?

10-20 days

Because of the sickle cell’s concave shape they are _______ of effective O2 transport and can cause ________

incapable; vascular occlusion

Which anemia is screened in all newborns in the US?

sickle cell anemia

When does anemia usually begin for sickle cell anemia?

4-6 months of age

What is considered immature hemoglobin?

fetal hemoglobin (HbF)

What is the only cure for sickle cell anemia?

bone marrow transplant

When are chronic blood transfusions indicated in sickle cell patients?

primary and secondary stroke prevention; debilitating pain; chronic organ failure

If blood transfusions are given monthly, what is the major complication?

iron overload, leading to liver failure

What is the treatment for iron overload?

PO = deferasirox and deferiprone OR IV = deferoxamine

What is the medication that can reduce sickling in sickle cell anemia?

hydroxyurea

What are the two meds that can be used to prevent complications in sickle cell anemia?

L-glutamine & Crizanlizumab

What is the MOA of hydroxyurea in SCD?

stimulates production of HbF

What are the BWs associated with hydroxyurea?

myelosuppression, secondary malignancy, embryo-fetal toxicity, avoid live vaccines

What are some AEs associated with hydroxyurea?

dry skin, hyperpigmentation, macrocytosis

What needs to be supplemented when using hydroxyurea?

folic acid

What is the monitoring parameter for hydroxyurea?

CBC w/ diff every 2-4 wks, then every 2-3 months

What is an important counseling point about hydroxyurea?

contraception required during and after treatment

How long should females be on contraception after treatment with hydroxyurea?

6 months

How long should males be on contraception after treatment with hydroxyurea?

6-12 months depending on brand

What is the MOA of L-glutamine in SCD?

amino acid that is thought to decrease oxidative stress leading to less sickle RBC damage

When is L-glutamine indicated in SCD?

adults and children >5 yrs

What formulation does L-glutamine come in?

oral powder that is dissolved in food or drink

When is hydroxyurea indicated in SCD?

adults w/ 3 moderate to severe pain crises in 1 year OR severe/recurrent chest syndrome OR chronic symptomatic anemia

What is the MOA of crizanlizumab in SCD?

blocks P-selection on surface of endothelial cells and platelets to prevent adhesion and vascular obstruction

What is the brand name for Crizanlizumab?

Adakveo

When is crizanlizumab indicated in SCD?

patients >16 yrs

What is the most common complication in SCD?

vas-occlusive crisis

How long should NSAIDs be used in SCD patient for vaso-occlusive crisis?

no more than 5 days

Chest pain + evidence of lung function in SCD patient =

acute chest syndrome

Which complication is the leading cause of death in SCD patients?

acute chest syndrome

What kind of organisms does a normal spleen clear infections from?

encapsulated organisms

What are some examples of encapsulated organisms?

strep pneumo, H. flu, and neisseria

In SCD, what happens to the spleen?

becomes fibrotic and shrinks which decreases spleen function

Due to functional asplenia in SCD patients, how do we prevent infections with encapsulated organisms?

prophylactic antibodies and immunizations (pneumococcal earlier than gen pop)

Infection prophylaxis in SCD patients =

penicillin from birth to age 5

What is the penicillin dose for SCD patients <3yrs?

125 mg PO BID

What is the penicillin dose for SCD patients >3yrs?

250 mg PO BID

What are the alternative prophylactic antibiotic options for SCD patients?

ceftriaxone or clindamycin

What are the recommended childhood vaccines for SCD patients?

HIb w/ dTap &IPV (Pentacel), PCV20, meningococcal conjugate series and meningococcal serogroup B (>10 yrs)

What is often used to control chronic pain in children w/ SCD?

APAP and NSAIDs

How is severe pain controlled in adults w/ SCD?

morphine equivalents

Which chronic pain med in SCD should not be used more than 48 hrs due to renal toxicity?

merperidine

group of diseases characterized by a decrease in either Hgb or Hct

anemia

What is considered anemic in men?

Hgb <13

What is considered anemic in women?

Hgb<12

Folate and Vitamin B12 deficient anemias are considered

nuclear maturation defect

Iron deficiency anemia is considered

hypoproliferative normocytic

What are some S/S of chronic anemia?

fatigue, weakness, vertigo, sensitivity to cold

What are some S/S of acute onset of anemia?

palpitations, angina, breathlessness, tachycardia, hypotension

What MCV values are considered normocytic?

MCV 80-100 fL

What MCV values are considered microcytic?

MCV<80 fL

What MCV values are considered macrocytic?

MCV>100 fL

What is the most common nutritional deficiency?

iron deficiency

What type of anemia does iron deficiency anemia present as?

microcytic

Which type of anemic patients may present with Pica (eating things that have no nutritional value)?

iron deficiency anemia

What are some causes of iron deficiency anemia?

inadequate dietary intake, blood loss, decreased iron absorption, increased iron requirements

Which patient groups are at risk of iron deficiency anemia?

<2 yrs or >65 yrs; adolescent girls; pregnant/lactating females

____ is essential for Hgb formation, electron transport and energy metabolism within cells

iron

What is the transport protein for iron?

transferrin

What is the storage iron called?

ferritin

What is the patho of iron deficiency anemia?

iron stores are reduced w/o reduced serum iron levels; iron stores are depleted; anemia develops

average volume of RBC =

mean cell volume (MCV)

concentration of iron bound to transferrin =

serum iron

What is the best indicator of iron deficiency or overload?

ferritin

iron binding capacity of serum transferrin =

total iron binding capacity (TIBC)

All lab values in iron deficiency anemia should be decreased except _____, which is increased

total iron binding capacity (TIBC)

What is the daily recommended allowance of iron?

8 mg in adults and 18 mg in menstruating females

Which type of dietary iron is preferred?

heme iron = animal products

What can increase absorption of iron?

gastric acid and ascorbic acid

What can decrease iron absorption?

milk, tea, Ca2+, TCAs, doxy, H2RAs and PPIs

How much elemental iron is in ferrous sulfate?

20%

How much elemental iron is in ferrous fumarate?

33%

What is the recommended daily dose of elemental iron?

150-200 mg

What is the duration of oral iron supplementation for iron deficiency anemia?

3-6 months to allow repletion of iron stores

What is the brand name for Iron Dextran?

Infed

What is the brand name for sodium ferric gluconate?

Ferrlecit