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Polycythaemia: mild polycythemia is normal in persons who exercise excessively and in persons who

live in high altitudespolycythemia vera:: is a disease state in which the rate of red cell production is
far greater than normal.

polycythaemia vera:: is a disease state in which the rate of red cell production is far greater than
normal, even though there is no physiological need for the increased production, it results from
some sort of tumor in the bone marrow

phlebotomy whenever the hematocrit rise above 55% may suffice as the only ttt for pts who do not
have sever thrombocytosis -- phlebotomy: opening a vein to let or draw blood, also called
venesection

drugs used include: busulfan (myleran),, radio active phosphorus 32P.

ALKYLATING AGENT

Busulfan – used with phenytoin and clonazepam

Causes myelosuppression, pulmonary fibrosis, addison like syndrome

Carmustine rapidly degrades in pvc container. Store in glass. Protect from light. Available topically as
well)

Cyclophosphamide (alkylating agent) ------- breast cancer, lymphoma – causes total BMD,
Haemorrhagic cystitis (treated with high dose IV cyclophosphamide and mesna

Procarbazine – alkylating agent – hodgkin lymphoma – myelosuppression

Intrathecal route – MTX, thiotepa, Cytarbine

ANTHRACYCLINES

Doxorubicin – Hand foot syndrome , red urine , causes cardiac cumulative toxicity Injection is red.

Liposomal prepration

Antimetabolites

Methotrexate folic acid antagonist. is effective in the treatment of chrohn’s disease (25 mg OD),
psoriasis , ectopic pregnancy, rheumatoid arthritis,

GI ulceration may worsen. CI in ulcerative colitis., causes BMD, pulmonary toxicity, hepatotoxicity

methotrexate +salicylates – bone marrow depression

folinic acid is antidote for methotrexate --- methotrexate is folic acid analogue used in leukemia

administered intrathecal. Excreted by GF.

Given once a week in RA

Flurouracil – pyrimidine antimetabolite. Angina like chest pain hand and foot syndrome

MCP – purine antimetabolite. Interacts with allopurinol – severe bone marrow toxicity . avoid
combination or reduce MCP dose to one quarter to one third of normal.(azathioprine is metabolised
to MCP)
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Thioguanine – purine antimetabolite


Platinum compounds

Cisplatin – displaces chloride ion. Ototoxicity, neurotoxicity

Nephrotoxic, exposure to platinum compounds in factory may cause allergic reaction to cisplatin or
carboplatin

More emetogenic, nephrotoxic than carboplatin.

cisplatin SE: proximal renal tubular damage

storage of cisplatin: at room temperature or from 15-25 C - SE: proximal renal tubular damage
(nephrotoxicity

Amifostine is used with cisplatin in regimen for ovarian cancer to reduce nephrotoxicity and
neurological toxicity without reducing the response rate.

storage of cisplatin: store from 15-25 C, do not refrigerate, protect from light, discard unused
portion

What would you say as a pharmacist to a nurse regarding cisplatin use? – do not administer or
prepare with equipments containing aluminium as it may cause precipitation and loss of potency.

PODOPHYLLOTOXIN

Etoposide

antineoplastic, have been approved for use in combination of (ex: cisplatin, vinblastin, bleomycin) in
pts with refractory ovarian and lung ,testicular tumors, small cell lung cancer who have already
received appropriate surgical, chemotherapeutic and radiation therapy

it holds promise in ttt of small cell liniing cancer and other carcinomas - it's a semisynthetic deriv of
podophyllotoxin, an active constituent of podophyllin. It acts as an inhibitor of cell mitosis

the marketed soln is diluted with D5W or 0.9% saline injection and given IV for a 60 min period..
Severe BMD is the most serious adverse effect, there is a high incidence (30%) of nausea and
vomiting

Placitaxel

AIDS related Kaposi sarcoma, Non small cell lung cancer. Formulated in castor oil

Albumin bound paclitaxel available.

Administration advice – Premedicate with dexamethasone and antihistamine and an H2 antagonist


to reduce the incidence and severity of hypersensitivity reactions ( 150 mg of paclitaxel contains 10
mg of ethanol – same as a standard drink.

Albumin bound – used for breast cancer . has lower incidence of hyoersensitivity reactions and
administration is easy. Does not contain castor oil and ethanol .

Does not require remedication to prevent hypersensitivity reactions .


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Vinca alkaloids
vincristine / vinblastine - FOR IV USE ONLY. FATAL IF GIVEN BY ANY OTHER ROUTE

Better tolerated in children than adults.

TO reduce risk of accidental intrathecal administration, prepare vincristine and vinblastine in a 50 ml


minibag. In children consider using a smaller volume in minibag and slower infusion rate .

Give prophylactic therapy fr constipation with docusate and senna

Non small lung cancer – vinorelbine

Antibacterials used in cancer chemotherapy

MAY INCREASE CHANCE OF GETTING INFECTION. CONTACT DOCTOR IF YOU EXPERIENCE FEVER ,
CHILLS OR ANY OTHER SIGNS OF INFECTION.

MaY BRUISE OR BLEED EASILY

pulmonary toxicity is SE of: bleomycin, amiodarone, nitrofurantoin, pentamidine, bromocriptine

dactinomycin, mithromycin are antibiotics and anticancer due to their cytotoxic effects

Bleomycin – Non Hodgkin lymphoma, germ cell tumour – testicular cancer ,

Surgery – high concentrations of supplemental oxygen may increase risk of pulmonary toxicity .
recent bleomycin treatment (within 2 months ) or a history of pulmonary toxicity due to bleomycin
may further increase the risk. For surgery les than 12 months after bleomycin treatment use lowest
oxygen concentration required to maintain adequate tissue oxygenation and carefully monitor fluid
replacement ( to reduce risk of pulmonary oedema.)

Dactinomycin

Injection is yellow.

DO not use in line filters as dactinomycin is removed by cellulose ester filters . Give by slow IV into
left arm for fast running infusion.

Mitomycin

Injection is dark blue/ purple

Non – cytotoxic antineoplastic

Premedication necessary with paracetamol . CORTICOSTEROIDS not used because they may have
additive effect on immunosuppression

Other non cytotoxic antineoplastics

BCG vaccine - - live attenuated mycobacterium bovis

Tumor lesions of bladder – bladder cancer

Precaution in genitourinary infection

Do not drink any fluid for 4 hrs before or for 2 hours the treatment is in your bladder
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After 2 hr period , urinate sitting in the toilet and disinfect the toilet by adding undiluted household
bleach to the bowl and leave for 15 minutes before flushing. Painful frequent urination fever and flu
symptoms.

Colaspase – kyowa unit

Coagulation abnormalities – thrombosis,

Tretinoin

Differentiation syndrome – usually develops during first few weeks of treatment and can be life
threatenening . Symptoms and signs include fever, weight gain, fever, peripheral oedema,
hypotension, acute renal failure, heart failure , pleural and pericardial effusion and pulmonary
infilterates. Start dexamethasone at he first signs withholding treatment r addition of hemotherapy
may be required.

Avoid laser refractive eye surgery for at least 6 months after using tretinoin as both can cause dry
eyes and impair healing.

Flutamide (antiandrogen)

Goserelin (gonadotropin releasing hormone agonist) – palliative prostate cancer. (insert SC into the
interior of abdominal wall)

Selective oestrogen receptor modulator – TAMOXIFEN – used in oestrogen dependent neoplasm

Ineffective as an adjuvant therapy. If taken for 5 years, reduces the rish of oestrogen receptor
dependent positive tumour. No effective on oestrogen receptor dependent negative tumour.

Granulocyte stimulating factors. – Fligrastim

filgrastim is a protein. filgrastim is granulocyte-colony stimulating factor which stimulates the


production of neutrophils. filgrastim ( granulocyto colonies stimulator) : ttt of BMD with sever
neutropenia

Calcium folinate – reduces toxicity of methotrexate. Used in acute methotrexate overdosage. Usually
strats 24 hours after methotrexate infusion. enhances cytotoxicity of fluorouracil. Reduces incidence
of bone marrow suppression with long term pyrimethamine therapy.

Exclude vit B12 deficiency before using calcium folinate as it can correct anaemia f vitamin B12
deficiency without preventing the associated neurological damage.

Give dose > 30 mg by IV. Oral absorption is saturable.

Mesna

Reduction and prevention in treatment of haemorrhagic cystitis due to cyclophosphamide and


ifosfamide . reduces the risk of bleeding from the bladder. (NOT USED TO TREAT CANCER)

IMMUNOSUPPRESANT

Triple drug treatment – immunosuppressant calcinurin inhibitors, corticosteroid, azathioprine

Quadruplet drug treatment – triple drug treatment plus induction course with immunosuppressant
antibody (antihymocyte globulin or basiliximab)
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Combining myelo suppressing drugs increases the likelihood of anaemia


Calcinurin inhibitor

Diltiazem is sometimes required to reduce dose

Cyclosporin

Rheumatoid arthritis, psoriasis, aplastic anaemia ulcerative colitis

Adv. Effects - nephrotoxicity , gingival hyperplasia, hirsutism,

oral soln (100mg/ml) is drunk immediately after mixing with milk, chocolate milk or orange juice an
IV dosage form is also marketed.

cyclosporine: immunosuppressant. cyclosporine may be administered concurrently with adrenal


corticosteroids BUT NOT with other immunosuppressive agents. losporine: cyclic polypeptide
immunosuppressant - nephrotoxicity in 25-30% of pts, synergism with other nephrotoxic drugs may
occur, HTN, hirsutism, gum hyperplasia

formulation contains ethanol (100 mg capsule or inj contains 100 mg ethanol.

clean your gum and teeth regularly.

tacrolimus

azathioprine + allopurinol:: increased levels of both drugs -- 6-MP + allopurinol:: increased levels of
both drugs

Corticosteroids

1) Cortisone (oral) and hydrocortisone are used for adrenal insufficiency


2) Cortisone with minimum mineralocorticoid activity - prednisolone , prednisone used as
immunosuppressant and anti- inflammatory agent.

Betamethasone (IM, intra-articular, intradermal, osft tissue injection) – used in neonatal


respiratory distress syndrome . fetal lung maturation . given IM- 11.4 mg single dose and second
dose after 24 hrs unless delivery occurs.

Adjunct treatment for rheumatoid arthritis , osteoarthritis and acute gout tendonitis,

Dexamethasone (oral, IV, IM, intra-articular, soft-tissue injection) – neonatal respiratory distress
syndrome., cerebral oedema

Hydrocortisone (oral, IV, IM)- acute severe asthama, anaphylaxis. As an adjunct treatment

Methylprednisolone – acute severe Asthama. IV administration is contraindicated.

Methylprednisolone- acetate -intra articular, intradermal, IM

Succinate – IV,IM

Prednisolone/prednisone – (oral)

Azathioprine – Allopurinol reduces azathioprine metabolism , increasing risk of severe bone


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marrow toxicity. Avoid combination or reduce azathioprine dose to one quarter.


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Oral Antineoplastic and emetogenicity (Low to Comments
high)
Low (<30%)
Busulfan (<4mg daily) No pretretment required
Cyclophosphamide (<100mg/m2)
Hydroxyurea
Melphalan, MCP
MTX
Tretinon
HIGH(>30%)
Busulphan (>4 mg daily) Require pretreatment with 5HT3 antagonist
Cyclophosphamide (>100mg/m2) Eg : Ondansetron
etoposide
Procarbazine
IV Antineoplastic and Emetogenicity (Low to
High)
Minimal emetogenic (<10%)
Colaspase (L-asparginase) No pretreatment required
Bleomycin
Fludarabine
MTX (<50mg/m2)
Vinca alkaloids
Low (10-30%)
Doxorubicin (liposomes)
Etoposide Require pretreatment with 5HT3 antagonist
Fluorouracil No prophyllaxis required.
MTX
Paclitaxel
Moderate (30-90%)
Arsenic trioxide
Busulphan Require pretreatment with dexamethasone and
Carbolplatin A 5HT3 antagonist . require prophyllaxis for
cyclophosphamide Delayed nausea and vomiting with
Dactinomycin, doxorubicin, daunorubicin Dexamethasone or a 5 HT3 antagonist
MTX,Melphalan
High(>90%)
Carmustine
Cisplatin Reuire pretreatment with dexamethasone
Cyclophosphamide 5HT3 antagonist or aprepitant (or fosaprepitant
Require prophyllaxis with aprepitant
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