61 Page 1 of

2012 exam
1. Clinical pharmacy activities During the prescription are :
a. Clinical trials
b. Formularies
c. Drug information
d. Counselling activity
2. Clinical pharmacy activities after the prescription are Except :
a. Formularies
b. Counselling activity
c. Preparation of personalised formulation
d. Drug use evaluation
3. The term of dose intensity (DI) is used to define
a. the drug dose delivered per time unit and is expressed as mg/m2 per week
b. the patient ideal body weight
c. the protocol identified dosage form
4. the mechanism of resistance to methotrexate is
a. decreased uptake of dihydrofolate
b. increased dihydrofolate reductase (DHFR) activity
c. a and b
5. Methotrexate mechanism of action is

a. decreased uptake of dihydrofolate

b. increased dihydrofolate reductase (DHFR) activity
c. folic acid analogue which inhibits dihydrofolate reductase
d.

all of the above

Methotrexate affect 1-C atom metabolism by

a. one-carbon transfer reactions requires specific coenzymes synthesized
in the cell from tetrahydrofolic acid
b. Methotrexate inhibit the cell from producing methylsalicylate
c. None of the above
7. Methotrexate inside the cell will be converted to
a. Polyglutamate form ,7 isomers
b. Acetate form , 7 isomers
c. All of the above
d. None of the above
8. TPMT is responsible for
a. Inactivation of 6MP
b. Activation of 6MP
c. All of the above
d. None of the above
9. Significant of D15 MRD results
a. Additional 3 asparaginase if MRD >1%
b. Not significant
c. Need additional Adriamycin
d. None of the above
10. Heterozygocity means
11. Loss of heterozygosity (LOH) in a cell represents
a. the loss of normal function of one allele of a gene
b. the loss of normal function of two alleles of a gene
c. All of the above
d. None of the above
6.

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12. Polymorphism

in TPMT will cause

a. Accumulation of active drug causing toxicity
b. Increasing the metabolism of the active drug reducing the effectiveness
c. All of the above
d. None of the above
13. When using Fludara and Cytosar together
a. Cytarabine can impair the metabolism of fludarabine.
b. Cytarabine can increase the metabolism of fludarabine
c. fludarabine can impair the metabolism of Cytarabine
d. fludarabine can increase the metabolism of Cytarabine
e. None of the above
14. Inhibition of phosphorylation of arabinosyl-2-fluoroadenine will result in
a. plasma levels of the active fludarabine triphosphate, F-ara-ATP, are
decreased.
b. plasma levels of the active fludarabine triphosphate, F-ara-ATP, are increased.
c. None of the above
15. F-ara-ATP can potentiate deoxycytidine kinase and will result in
a. the phosphorylation of cytarabine. As a result, plasma levels of the
active cytarabine triphosphate, ara-CTP, are increased.
b. the phosphorylation of cytarabine. As a result, plasma levels of the active
cytarabine triphosphate, ara-CTP, are decreased
c. None of the above
16. When using Fludara and Cytosar together
a. cytarabine be given as a relatively short-term infusion following
fludarabine
b. We can not use both together
c. None of the above
17. Pharmacogenetics,
Pharmacogenetics is generally regarded as the study or clinical testing of
a. genetic variation that gives rise to differing response to drugs
b. genetic differences in metabolic pathways which can affect individual
responses to drugs, both in terms of therapeutic effect as well as adverse
effects
c. All of the above
d. None of the above
18.The Intrathecal therapy is given to
a. CNS prophylaxis
b. Systemically increase the level of methotrexate
c. All of the above
d. None of the above
19. Methotrexate ,Cytosar and Hydrocortisone
a. Can be given together as intrathecal injection
b. Drug drug interaction prevent co-administration
c. None of the above
20. Vincristine
a. Is Fatal if given intrathecally
b. Is only given intrathecally
c. None of the above

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21. Prognosis is
a. the prior knowledge of outcome of a disease
b. the increase in intensity of therapy
c. All of the above
d. None of the above
22. In Acute lymphoblastic leukemia a child with 12 years will be
a. Bad prognosis
b. Good prognosis
c. Not a prognostic factor
d. None of the above
23. The gene function is expression of
a. Proteins
b. Chromosomes
c. All of the above
d. None of the above
24. Asparaginase is
a. an enzyme that catalyzes the hydrolysis of asparagine to aspartic acid
b. an anticanceralkylating agent
c. All of the above
d. None of the above
25. Storage of Asparaginase Medac
a. Must be in the refrigerator
b. Can be in Room temperature
c. All of the above
d. None of the above
26. Calculating a dose of Asparaginase Medac 10000 international units in a 0.8
m2 child will be
a. 4000 international units
b. 8000 international units
c. None of the above
27. It has been suggested that cytarabine be given as a relatively short-term
infusion following fludarabine to
a. minimize metabolic interference with the subsequent fludarabine dose
b. maximize ara-CTP synthesis.
c. All of the above
d. None of the above
28. 2ry malignancy can occur with following medications
a. VP16
b. prednisone
c.All of the above
d. None of the above
29. The TPMT polymorphism is significant for the dosing and toxicity of: a.
Dexamethasone
b.

6-thioguanine

c.

6-mercaptopurine

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30. In Induction chemotherapy for All the goal of induction therapy is to
a.

Bring the disease into remission

b.

To reduce the number of disease cells left in the body

c.
d.

To destroy any disease cells that remains

None of the above

e.

All of the above

31.The goal of consolidation therapy for All is

a.

Bring the disease into remission

b.

To reduce the number of disease cells left in the body

c.
d.

To destroy any disease cells that remains

None of the above

e.

All of the above

32. The goal of Maintenance Therapy for ALL is

a.

Bring the disease into remission

b.

To reduce the number of disease cells left in the body

c.
d.

To destroy any disease cells that remains

None of the above

e.

All of the above

33. which of the following is good prognosis for ALL

a. MLL rearrangement
b. Hyperdiploidy
34. Another name for BCR-ABL fusion gene is __________chromosome
a. Phildelphia chromosome
b. BCR1
c. None of the above
35. A patient is taking Enoxeprine for coagulopathy and his due to receive his
intrathecal after tomorrow ,what instructions should the pharmacists tell
the patient?
a.nothing
b.stop Enoxeprine 24 hrs before the procedure
c.continue Enoxeprine
36. Dexamethasone is used for Brain tumor patients during Chemotherapy
a.T
b.F
37. The best hope for continued progress lies in the better understanding of the
a.pathogenesis of ALL
b.basis of resistance to chemotherapy
c.all of the above

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38. Evidence based practice (EBP) is the thorough, concise, and sensible use of the
a. current best evidence in making decisions about the care of individual
patients.
b. intituition
c. physician experience

39. Evidence base practice considers:

a.the benefits and risk of other patient management strategies,
b. the role of patients values and preferences in trading off those benefits and
risks.
c. a and b
40. In ALL Risk directed therapy
a.High risk treatment was Anti-metabolite based
b.Standard risk treatment was Intensive Multi-agent
c.Low risk treatment was Allogeneic Transplantation
41. Adverse Prognostic Factors in the 1990s for ALL were
a. Age<1, > 10 years
b.Decreased WBC
c.White race
42. this curve shows that worst survival is for D15 BM

a.0% blasts
b.1-4% blast
c.> 5% blast

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43. The following figure stands for

a. Risk classification schema

b. staging of leukemia
c. None of the above
44. looking to this curve the following is true

a.E. Coli is less effective

b.Erwinia is less effective
45. looking to the following curve what should you recommend

a. one reinduction
b. double reinduction
46. Toxicities Associated with CNS Irradiation are
a.Second malignancy
b.Neuropsychologic dysfunction

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c.Endocrinopathy
d. all of the above
47. Principles of Treatment in ALL includes
a. Risk-directed therapy
b. delayed intensification of chemotherapy
c. short continuation treatment
48. The discipline of pharmacoeconomics is defined as the science of
a. measuring the costs and outcomes associated with the use of pharmaceuticals
in health care delivery.
b. measuring the outcomes associated with the use of pharmaceuticals in health care
delivery.
c. measuring the costs associated with the use of pharmaceuticals in health care
delivery.
49. Change is like a dragon what should you do
a. Fight it.
b.Ignore it
c. ride it.
50. In 57357 the cure rate for ALL is aimed to be
a.40%
b. 50%
c. 80%
51. In total 15 protocol , dose of methotrexate for ALL SR is.
a- 2500 mg/m2
b- 1125 mg/m2
c- 5000 mg/m2
1250 mg/m2
52. Pharmaceutical care is
aIndividual patient oriented service
b- Disease
oriented service
c-Product oriented service
d - Doctor
oriented service
53. Clinical pharmacy service started from ..
a- 1950
b- 1970
c- 1960
d- 1990
54. Pharmaceutical care planning is written, individualized, a systematic,
comprehensive process.
aWritten & individualized
b- real &
individualized
c- accurate & real
d- all answers are correct
55. primary function of Pharmaceutical care planning is
a- Identify a patient's actual and potential drug-related problems.
b- Resolve the patient's actual drug-related problems.
c- Prevent the patient's potential drug-related problems.
d- all answers are correct
56. All of these are related drugs problems except
aFailure to receive drugs
b- Overdose
c- Patient education
d- Drug interactions

d-

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57. Clinical Pharmacist can reduce to . of direct cost of drug related
problems.
a- 20%
b- 30%
c- 40%
d- 50%
58. All of these are steps of the care planning process except
a- Creation of a comprehensive patient database.
b- Assess drug-related problems.
c- Patient clinical examination.
d- Establish therapeutic goals.
59. Source of patient database is
a- Patient family.
b- Patient profile.
c- Patient doctor.
d- Patient history.
60. For assess drug-related problems we should...
a- Review patient profile.
b- Determine additional drug therapy is needed.
c- Determine if any of the drug-related problems may have been caused by
medication.
d- All answers are correct.
61. Patient counseling is defined as providing medication information orally or in
written form to the patients or their representatives on:
a. directions of use
b. advice on side effects
c. storage
d. diet and life style modifications
e. All
f. only a,b,c
g. None
62. . .. is the one who sees the patient and the Medications just
before administration.
a.Nurse
b.Pharmacist
c.Physician
d.All
e.None
63. .One of the following is right :
a.Pharmacists with poor communication skills and excellent clinical
knowledge are more likely to be successful than pharmacists with
excellent communication skills and good clinical knowledge.
b.Pharmacists with excellent communication skills and good clinical
knowledge are more likely to be successful than pharmacists with poor
communication skills and excellent knowledge.
c.Pharmacists with excellent communication skills and good clinical
knowledge are more likely to be successful than pharmacists with
excellent communication skills and excellent knowledge.
d.All
e.None
64.Only with smart communication, Pharmacist will be able to provide
the following:

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a.Design Pharmaceutical Care Plan
b.Achieving Successful Clinical Intervention
c.Patient Counseling
d.All
e.Only a,b
f.Only b,c
g.Only a,c
h.None
65.The following may influence the process of patient counseling except:
a.Cost of medication
b.Pharmacist communication skills
c.Patient culture
d.Availability of medical information
e.All
f.None
66.Considerations throughout Patient Interview:
a.Rapport
b.Successful Communication
c.Patient-centered language
d.All
e.None
67.In order to attract patient attention and to ensure positive response to
information provided through patient counseling, pharmacist should :
a.Show professionalism during interview by talking with patient about
drug pharmacokinetics
b.Skip patient complaints about his drugs which may not be -according
to references- of clinical importance
c.Highlight and describe prescription errors committed by the
prescriber and the corrections
d.Stand very close to patient
e.Focus on medications and medical conditions
f.Use medical terminology during patient interview.
g.All
h.none
68.The first step of patient counseling is:
a.Providing information
b.Non drug options
c.Gathering patient information
d.None
69.The last step of patient counseling:
a.Follow up and closure
b.Providing information
c.Non drug options
d.Gathering patient information
e.None
70.The following is not important information to provide through patient
counseling:
a.Medication identity
b.Indications
c.Onset of action.

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d.Potential interactions or therapeutic contraindications
e.Side effects
f.All
g.None
a.
b.
c.
d.

71. All of the following from the common side effects of chemotherapy except:
Nausea
Vomiting
Headache
Mucositis

72-Neo-adjuvant chemotherapy means:

a. Make a tumor smaller before surgery
b. Destroy the tumor after surgery
c. Use chemotherapy with radiotherapy
d. None of the above
73-The goal of using chemotherapy with radiotherapy in some types of cancer is:
a. Increase efficacy of the chemotherapy
b. Decrease the side effect of the chemotherapy
c. Increase the cancer cell sensitivity to radiation
74-All of the following are Asparaginase side effects except :
a. Hyperglycemia
b. Anaphylaxis
c. Loss of tendon reflex
d. Thrombosis
75-The max dose of vincristine is :
a. 2 ml
b. 2mg
c. 20 mg
d. 0.2 ml
76-Before Doxorubicin administration you must check:
a. Random blood sugar
b. ECHO
c. Blood pressure
d. Creatinine clearance
77-Doxorubicin is infused over;
a. 2 hr
b. 23 hr
c. 4 hr
d. Iv push
78-Before Etoposide you must check:
a. Random blood sugar
b. ECHO
c. Blood pressure
d. Chest x-ray

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79-Cisplatin is infused over :
a. 24 hr
b. 6hr
c. 4hr
d. 2hr
80-Before Methotrexate infusion you must check :
a. Chest x-ray
b. ECHO
c. Blood pressure
d. Random blood sugar

81. MR DK ,71 year, male, metastatic Carcinoma of the colon was admitted for the 4th
cycle of second-line chemotherapy.Medications:
Atropine 250 ug, sc
Irinotecan 350 mg IV
5FU 800 mg IV
Folinic Acid 175 mg IV
82. How does Irinotecan act?
a. Topoisomerase I inhibitor
b. Topoisomerase II inhibitor
c. Alkylating agent
d.Antimetabolites
83. Irinotecan is converted by carboxylesterases to its more active metabolite, 7-ethyl10 hydroxy-camptothecin, or SN-38. T F
84.according this curve

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a.In the comparative trial vs 5-FU, CAMPTOSAR increased median survival

b.In the comparative trial vs 5-FU, CAMPTOSAR decreased median survival
85. The clinical activity of both 5-FU/leucovorin and irinotecan in patients with
metastatic colorectal is clinically attractive. There is reason to believe, however, that
this therapeutic combination may result in antagonism.
a. 5-FU may inhibit the DNA synthesis required for the cytotoxicity of SN-38.
b. SN-38 may cause cells to accumulate in the G2 rather than in the S phase
c. a and b

86. Fluorouracil is converted to FdUMP, leading to

a.inhibition of TS
b.depletion of deoxythymidine triphosphate (dTTP) pools
c. inhibition of DNA synthesis, resulting in G1/S cell-cycle arrest.
d. all of the above
87.The active metabolite of irinotecan, SN-38,
a. stabilizes the covalent complex between topoisomerase I and nuclear DNA
b.lead to DNA double-strand breaks
c. lead to accumulation of cells in the G2 phase of the cell cycle.
d. all of the above
89. Mullany et al observed a sequence-dependent interaction of SN-38 and 5-FU
plus leucovorin T F

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90. Mullany et al observed a sequence-dependent interaction of SN-38 and 5-FU plus
leucovorin so
a. Irrinotecan should be administered first
b. 5-FU should be administered first
91. The doselimiting toxicities of irinotecan is/are
a.diarrhea
b.neutropenia
c. a and b
92. Two distinct types of diarrhea associated with irinotecan have been identified
a.an early onset
b. lateonset diarrhea.
c. a and b
93. early onset types of diarrhea associated with irinotecan are called
a. nervous syndrome
b. cholinergic syndrome
c. Gilberts syndrome
94. Acute events of diarrhea are managed successfully by administering
a. IV or SC atropine 0.25 to 1.0 mg
b. Loperamide
c. Senna extract
95. Late events of diarrhea are managed successfully by administering
a. IV or SC atropine 0.25 to 1.0 mg
b. Loperamide
c. Senna extract
96. Avoid grapefruit, pomegranate, starfruit, Seville oranges, their juices or products
during irinotecan treatment T F
97. The concurrent administration of irinotecan with irradiation is not recommended
TF
98. Freezing irinotecan of irinotecan should be done . T F
99. irinotecan should be labeled Protect from light T F
100. How do genetic polymorphisms to UGT1A1*28 increase the risk for lifethreatening neutropenia when receiving irinotecan?

Patients at greatest risk for toxicity are those over the age of 65, those having
previously received pelvic/abdominal irradiation, patients with low
performance status, and patients heterozygous (TA6/TA7) or homozygous
(TA7/TA7) for UGT1A1*28 allele.
101. What does heterozygous and homozygous mean?

Since all humans have 2 copies of a gene coding sequence (or allele), a person
is heterozygous if they carry 1 copy of the normal gene and 1 copy of the
mutant gene and are homozygous if they have two identical copies of the
mutant gene (or gene variation).

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102. what role does UGT1A1*28 polymorphism play in causing irinotecaninduced myelosuppression?

patients with UGT1A1*28 make less UGT1A1 than normal patients and thus
cannot efficiently metabolize the potent irinotecan metabolite, SN-38.
103. Which of the following is the main metabolite of irinotecan?
a. SN-38
b. T20
c. 3A4
d. SN-21
104 . What side effect is a patient at greatest risk of developing if they are
homozygous for UGT1A1*28 and receiving irinotecan?
a. Congestive heart failure
b. Depression
c. Severe neutropenia
d. Arthritis
105. GW is a 61-year-old man who presents to your clinic with a chief complaint of
abdominal discomfort and cramping for the past 3 weeks not relieved with over-thecounter medications. While obtaining your medical history, he states that he also has
seen small amounts of blood in his stool on and off for 4 months. He has a past
medical history positive for hypertension and obesity. He states that he has smoked 1
pack of cigarettes per day for the past 40 years and drinks 4 to 6 beers every couple of
days.
What risk factors does GW have for colon cancer?
Does he have clinical symptoms suggestive of colon cancer?
What additional tests need to be ordered to diagnosis colon cancer?
106. 5-Flurouracil-based chemotherapy is the standard regimen used in adjuvant
treatment of colon cancer T F
107. Adjuvant therapy consisting of 5-fluorouracil-based chemotherapy in
combination with radiation therapy should be offered to patients with stage II or III
cancer of the rectum. T F
108. How does Mitomycin acts?
a. bifunctional and trifunctional alkylating agent
b. antimetabolites
c. spindle poison
109. Mitomycin is cell cycle
a.phase-nonspecific.
b. phase-specific
110. 5FU is cell cycle
a.phase-nonspecific.
b. phase-specific
111. Irrinotecan is cell cycle
a.phase-nonspecific.

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b. phase-specific
112. MM ,68 Y., Non Small cell Lung Cancer taking 1st course of MIT
chemotherapy
Mitomycin 6mg/m2
Ifosfamide 3 g/m2
Mesna
Cisplatin 50 mg/m2
GFR 50ml/min
Main ADR of MIT is /are?
a. Myelosuppression, Nausea and vomiting
b. Pulmonary toxicity
c.hemolytic-uremic syndrome
113. The incidence of cardiotoxicity may be increased
a. in patients receiving mitomycin in combination with doxorubicin
b. in patients who have had prior exposure to doxorubicin
c. a and b
114. Radiation recall reactions is caused by
a.5FU
b. Irrinotecan
c. Mitomycin
d. a and c
115.Myelosuppression has not been noted with intravesical administration of
Mitomycin . T F
116. MM, 30 y, 3rd course of 3 days BEP chemotherapy Bleomycin, Etoposide,
Cisplatin is treatment for
a. Testicular cancer
b. Breast Cancer
c. Lung Cancer
d.Endometrial cancer

117. MM,30 y,3rd course of 3 days BEP chemotherapy Pigmentation on his back and
marked acne Swelling and tenderness of finger tips What could be the cause of the
patient skin condition?
a. Bleomycin, b. Etoposide, c. Cisplatin
118. Bleomycin is
a.phase-nonspecific.
b. phase-specific
119. RH ,54 y, female ,stage III ovarian cancer should take a cycle of
a. MIT
b. carboplatin and paclitaxel
c.FAC

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120. RH ,54 y, female ,stage III ovarian cancer should take ,2nd cycle of
carboplatin and paclitaxel 175 mg/m2 .Nausea in the first few days post
chemotherapy Pain in the back of her legs (last week) 1.68 cm Ht, wt62 kg and GFR
73 ml/minWhat caused Leg pain?
a.carboplatin
b. paclitaxel
121. How does carboplatin act ?
Highly reactive platinum complexes are formed intracellularly. These complexes
inhibit DNA synthesis through covalent binding of DNA molecules to form
intrastrand and interstrand DNA crosslinks.
122. Carboplatin is considered to be
a.phase-nonspecific.
b. phase-specific
123. PA 60 y, male,Stage IIB Lung Cancer Surgical resection and receive
carboplatin and docetaxel What type of chemotherapy is he receiving?
a. neo-adjuvant
b. adjuvant
124. Docetaxel is considered to be Cell cycle specific
a. G phase
b. S phase
c. M phase

124.

a. Yes
b. NO

Does combination carboplatin and docetaxel provide advantage?

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125. Docetaxel-induced fluid retention is generally reversible but may be severe
with ascites, and pleural or pericardial effusions. Peripheral edema can be treated with
standard measures
a.sodium restriction
b. diuretics
c. a and b
126. The incidence and severity of Docetaxel-induced fluid retention increase in
incidence with
a. age
b. risk factors
c. cumulative doses of 400 mg/m2 or greater
127. Docetaxel-induced fluid retention Premedication with oral corticosteroids has
been reported to delay the onset and decrease the severity of fluid retention, and all
patients should receive premedication. Patients with existing effusions should be
monitored closely from the first dose to detect possible exacerbations of effusions.
128. AM ,45 y ,male , testicular cancer ,Cisplatin plus amofostine , ondansetron and
diazepam prior to each session.
Total protein 3.4 g/dl
Albumin 2 g/dl
Plt 100 000 /mm3hb 9.8 g/dl
WBC 2.9 X 10 9
How does cisplatin work?

Cisplatin is an inorganic complex formed by an atom of platinum surrounded

by chlorine and ammonia atoms in the cis position of a horizontal plane.
Intracellularly, water displaces the chloride to form highly reactive charged
platinum complexes. These complexes inhibit DNA through covalent binding
leading to intrastrand, interstrand, and protein cross-linking of DNA, leading
to apoptosis.
129.What are major Cisplatin ADRs?

The major dose limiting toxicity of cisplatin is cumulative nephrotoxicity

Nephrotoxicity Hypomagnesemia (magnesium wasting) severe nausea and
vomiting Neurotoxicity Ototoxicities
130.What is the rationale for combining cisplatin and amifostine?
Amifostine is a cytoprotective adjuvant used in
cancer chemotherapy involving DNA-binding chemotherapeutic agents. Also
commonly known as WR-1065 in its active form. It is marketed
by MedImmune under the trade name Ethyol.
Amifostine is used therapeutically to reduce the incidence of neutropeniarelated fever and infection induced by DNA-binding chemotherapeutic agents
including alkylating agents (e.g.cyclophosphamide) and platinum-containing
agents (e.g. cisplatin). It is also used to decrease the cumulative
nephrotoxicity associated with platinum-containing agents. Amifostine is also
indicated to reduce the incidence of xerostomia in patients undergoing
radiotherapy for head and neck cancer.
Amifostine is an organic thiophosphate prodrug which is hydrolysed in
vivo by alkaline phosphatase to the active cytoprotective thiol metabolite. The
selective protection of non-malignant tissues is believed to be due to higher

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alkaline phosphatase activity, higher pH, and vascular permeation of normal
tissues.
131. Amifostine can only be administered___________________________,
a. s.c.
b. intravenously
c. I.M
d.oral
132. Amifostine after reconstitution with
a. G5%
b. G/NS
C. NS
133. Amifostine Infusions lasting less than 15 minutes decrease the risk of adverse
effects. T F
134. With Amifostine Infusions the patient should be well-hydrated before
administration. T F
135. Discuss rational for using the following medication in this case ;
AM ,45 y ,male , testicular cancer ,Cisplatin plus amofostine , ondansetron and
diazepam prior to each session.
Total protein 3.4 g/dl , Albumin 2 g/dl , Plt 100 000 /mm3hb 9.8 g/dl
WBC 2.9 X 10 9
a. Ondansetron
Antiemetic regimen (I will add dexa and avil )
b.Diazepam
Antiemetic for delayed and breakthrough
136. Tumor resistance to methotrexate:
a.decreased drug transport into the cell
b.altered dihydrofolate reductase enzyme -- lower affinity for methotrexate
c.decreased polyglutamate formation
d. quantitative increase in dihydrofolate reductase enzyme concentration in the cell
e. all of the above
137. Methotrexate is considered to be Cell cycle specific
a. G phase
b. S phase
c. M phase
138. The most common adverse effects of Methotrexate are(3)

stomatitis, myelosuppression gastrointestinal effects

139. Renal toxicity form Methotrexate may be related to precipitation of methotrexate
in the renal tubules and collecting ducts.
140.Urinary methotrexate levels in excess of 1 mmol/L exceed the solubility of
methotrexate at pH 5.0 and promote drug precipitation.
141.The risk of renal failure due to high-dose methotrexate (>1 g/m2) can be
minimized by

diuresis, alkalinization of the urine (adjust urinary pH with IV sodium

bicarbonate to maintain >7.0).
142. Clearance of methotrexate is delayed in the presence of fluid in the third space
(e.g., pleural effusions, ascites), and toxicity may be enhanced. It is recommended

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a. CXR before every dose
b. measure creatinine clearance
c. measure liver functions
d. Increase hydration
143.

1.

a.damages DNA by intercalation, metal ion chelation,

b.generats of free radicals.
c.inhibit DNA topoisomerase II which is critical to DNA
function.
d. Cytotoxic activity is cell cycle phase non-specific.

2.

b.causes prevention of cell division primarily by cross-linking

DNA and RNA strands.
c. It is considered to be cell cycle phase-nonspecific.
The active form inhibits DNA synthesis by inhibiting
thymidylate synthetase and the normal production of
thymidine.

3.

a. 5-FU
b. Doxorubicin

1 2 3
1 2 3
c. Cyclophosphamide
1 2 3
135. 5 FU Effects on RNA occur especially with
a. bolus administration
b. Continuous Infusion
136. Fluorouracil is cell cycle phase-specific
a. G phase
b. S phase
c. M phase

137. Principles of combination chemotherapy

(1) It provides maximum cell kill within the range of toxicity tolerated by the
host for each drug;
(2) it offers a broader range of coverage of resistant cell lines in a
heterogeneous tumor population;
(3) it prevents or slows the development of new drug-resistant cell lines.
138. Safety in administration of Herceptin
Mix in 250 mL bag NS. Do not use D5W. Do not shake.
Infuse loading dose IV over 90 minutes; subsequent infusions may be given
over 30 minutes if the initial loading dose is well-tolerated.

61 Page 20 of

DO NOT ADMINISTER AS AN IV PUSH OR BOLUS.

Should not be mixed or diluted with other drugs.
Herceptin infusions should not be administered or mixed with Dextrose
solutions.
Diluent supplied - Bacteriostatic Water for Injection (BWFI)- contains benzyl
alcohol 1.1%; if patient is hypersensitive to benzyl alcohol, may reconstitute
with Sterile Water for Injection, but must be used immediately and discard
unused portion. =
Solution reconstituted with the supplied BWFI is stable up to 28 days
refrigerated.
Do not freeze the reconstituted solution

139.
Abbreviation

Tumor marker

CEA

Carcinoembryonic Antigen

CA-125

Cancer Antigen-125

Significance
malignancies arising in entodermal
(embryonic) or gastrointestinal
tissue.
Persistent elevated levels indicate
residual or recurrent metastatic
carcinoma.
monitoring for ovarian cancer by
measuring an antigen to epithelial

61 Page 21 of

AFP

Alpha-fetoprotein

PSA

Prostate Specific Antigen

ERA

Estrogen Receptor Assay

PRA

Progesterone Receptor Assay

LDH
HCG

Lactic Dehydrogenase
Human Chorionic
Gonadotropin

neoplasms circulating in blood

serum
Serum levels elevated in
Hepatocellular cancer. also found in
certain ovarian and teratocarcinoma
or embryonal carcinoma of the
testis.
may be elevated in benign prostatic
hypertrophy; greatest elevation
occurs in stage C and D prostate
cancer. After radical prostatectomy
or radiation therapy, rising levels of
PSA indicate residual disease or
recurrence. Note: test results may
be affected by recent prostatic
massage or palpation
A laboratory test of breast cancer
tissue to determine the
responsiveness of the tumor to
endocrine therapy or to removal of
the ovaries. Tumors which are
negative for estrogen receptors
rarely respond to hormone
manipulation
determine the responsiveness of
breast cancer to endocrine therapy
or to removal of the ovaries.
Progesterone receptor assay
increases the reliability of estrogen
receptor assay results.a positive
progesterone receptor assay
indicates greater likelihood that the
patient will respond to hormone
therapy
All tumors produce LDH
A nonspecific marker for
pancreatic, pituitary, and placental
tumors; elevated levels may be
present in pancreatic cancer.

TUMOR MARKERS

CANCERS

WHAT ELSE?

WHEN/HOW USED

USUAL
SAMPLE

AFP (Alpha-feto

Liver, germ cell cancer of

Also elevated during pregnancy

Help diagnose, monitor

Blood

protein)

ovaries or testes

treatment, and determine

recurrence

B2M (Beta-2

Multiple myeloma

Present in many other conditions,

Determine prognosis

Blood

61 Page 22 of

TUMOR MARKERS

CANCERS

WHAT ELSE?

microglobulin)

and lymphomas

including Crohn's disease and hepatitis;

WHEN/HOW USED

USUAL
SAMPLE

Blood

often used to determine cause of renal

failure

CA 15-3 (Cancer

Breast cancer and others,

Also elevated in benign breast

Stage disease, monitor

antigen 15-3)

including lung, ovarian

conditions; doctor can use CA 15-3 or

treatment, and determine

CA 27.29 (two different assays for same recurrence

marker)

CA 19-9 (Cancer

Pancreatic, sometimes colorectal Also elevated in pancreatitis and

Stage disease, monitor

antigen 19-9)

and bile ducts

treatment, and determine

inflammatory bowel disease

Blood

recurrence

CA-125 (Cancer

Ovarian

antigen 125)

Calcitonin

Thyroid medullary carcinoma

Also elevated with endometriosis, some Help diagnose, monitor

other benign diseases and conditions;

treatment, and determine

not recommended as a general screen

recurrence

Also elevated in pernicious anemia and Help diagnose, monitor

thyroiditis

Blood

Blood

treatment, and determine

recurrence

CEA (Carcino-

Colorectal, lung,

Elevated in other conditions such as

embryonic antigen)

breast, thyroid, pancreatic, liver, hepatitis, COPD, colitis, pancreatitis,

Monitor treatment and

Blood

determine recurrence

cervix, and bladder

and in cigarette smokers

Chromogranin A

Neuroendocrine tumors

May be most sensitive tumor marker for To help diagnose and

(CgA)

(carcinoid tumors,

carcinoid tumors

Blood

monitor

neuroblastoma)

Estrogen receptors

Breast

Increased in hormone-dependent cancer Determine prognosis and

Tissue

guide treatment

hCG (Human

Testicular and trophoblastic

chorionic

disease

Elevated in pregnancy, testicular failure Help diagnose, monitor

treatment, and determine

gonadotropin)

Her-2/neu

Blood,
urine

recurrence

Breast

Oncogene that is present in multiple

Determine prognosis and

Tissue

61 Page 23 of

TUMOR MARKERS

CANCERS

WHAT ELSE?

WHEN/HOW USED

copies in 20-30% of invasive breast

guide treatment

USUAL
SAMPLE

cancer

Monoclonal

Multiple myeloma and

Overproduction of an immunoglobulin

immunoglobulins

Waldenstroms

or antibody, usually detected by protein monitor treatment, and

macroglobulinemia

electrophoresis

Breast

Increased in hormone-dependent cancer Determine prognosis and

Progesterone
receptors

Help diagnose,

Blood,
urine

determine recurrence

Tissue

guide treatment

PSA (Prostate specific Prostate

Elevated in benign prostatic hyperplasia, Screen for and help

antigen), total and

prostatitis and with age

free

Blood

diagnose, monitor
treatment, and determine
recurrence

Thyroglobulin

Thyroid

Used after thyroid is removed to

Determine recurrence

Blood

Not widely available, but gaining

Help diagnose and

Urine

acceptance

determine recurrence

No evidence that it is better than CA-

Help diagnose

Blood

To evaluate risk of

Blood

evaluate treatment

Other Tumor
Markers Less
Widely Used

BTA (Bladder tumor

Bladder

antigen)

CA 72-4 (Cancer
antigen 72-4)

Ovarian

125 but may be useful when combined

with it; still being studied

Des-gamma-carboxy
prothrombin (DCP)

Hepatocellular carcinoma (HCC) New test; often used along with an

imaging study plus AFP and/or AFP-

developing HCC; to

L3% to evaluate if someone with

evaluate treatment; to

61 Page 24 of

TUMOR MARKERS

CANCERS

WHAT ELSE?

WHEN/HOW USED

chronic liver disease has developed

monitor for recurrence

USUAL
SAMPLE

HCC

EGFR (Her-1)

Solid tumors, such as of the lung Not available in every laboratory

Guide treatment and

(non small cell), head and neck,

determine prognosis

Tissue

colon, pancreas, or breast

NSE (Neuron-specific Neuroblastoma, small cell lung

May be better than CEA for following

enolase)

cancer

this particular kind of lung cancer

NMP22

Bladder

Not widely used

Monitor treatment

Blood

Help diagnose and

Urine

determine recurrence

Prostate-specific

Prostate

membrane antigen

Not widely used; levels increase

Help diagnose

Blood

Help diagnose

Blood

Help diagnose

Blood

normally with age

(PSMA)

Prostatic acid

Metastatic prostate cancer,

Not widely used anymore; elevated in

phosphatase (PAP)

myeloma, lung cancer

prostatitis and other conditions

S-100

Metastatic melanoma

Not widely used

Soluble Mesothelin-

Mesothelioma

Often used in conjunction with imaging To monitor progression or Blood

Related Peptides

tests

recurrence

Not widely used, being studied

Help diagnose

(SMRP)

TA-90

Metastatic melanoma

140.

Drug interactions

Blood

61 Page 25 of

Drugs

Consequence of interaction

Procarbazine +

May cause an abrupt

Sympathomimetics or

increase in BP, resulting in a

tyramine-containing food

potentially fatal hypertensive

crisis (procarbazine is a weak

Procarbazine

MAOI)
Procarbazine is cyp450

inhibdec metab of BDZ &

Benzodiazepines
Interleukin-2 +

barbiturates & narcotics

Antihypertensive drugs
Interleukin-2 + Doxorubicin

effects

Cause enhanced hypotensive

Increase risk of

Interleukin-2 +

cardiotoxicity
Increase risk of

Aminoglycosides
Interleukin-2 +

nephrotoxicity
Increase risk of

Asparaginase
Paclitaxel + Cisplatin

hepatotoxicity
- Platinum Derivatives may
enhance the
myelosuppressive effect of

Mercaptopurine +

paclitaxel.
-Allopurinol may decrease

Allopurinol

the metabolism of
Mercaptopurine
( Allopurinol inhibits
xanthine oxidase, the
enzyme responsible for
metabolism of

Asparaginase +

mercaptopurine
Asparaginase may diminish

Methotrexate

or abolish methotrexate's
effect on malignant cells.

61 Page 26 of

Carmustine+Cimetidine: May decrease the metabolism of Carmustine

Cisplatin+furosemide : May enhance the nephrotoxic effect of CISplatin. Loop
Diuretics may enhance the ototoxic effect of CISplatin. Risk C: Monitor therapy
Cisplatin+Aminoglycosides: CISplatin may enhance the nephrotoxic effect of
Aminoglycosides. Risk C: Monitor therapy
Methotrexate+Penicillins: May decrease the excretion of Methotrexate. Risk C:
Monitor therapy
Methotrexate+Bile Acid Sequestrants(cholestyramine):
absorption of Methotrexate. Risk C: Monitor therapy

May

decrease

the

Methotrexate+ (salicylate)Nonsteroidal Anti-Inflammatory Agents: May decrease

the excretion of Methotrexate. Risk D: Consider therapy modification
Methotrexate+Probenecid: May increase the serum concentration of Methotrexate.
Management: Avoid concomitant use of probenecid and methotrexate if possible. If
used together, consider lower methotrexate doses and monitor for evidence of
methotrexate toxicity. Risk D: Consider therapy modification
Methotrexate+alcohol: the increased risk of liver damage is significant for people
who are drinking alcohol while taking methotrexate
Estramustine+Calcium Salts: May decrease the absorption of Estramustine.
Exceptions: Calcium Chloride. Risk D: Consider therapy modification
Tamoxifen+Vitamin K Antagonists (eg, warfarin): Tamoxifen may increase the
serum concentration of Vitamin K Antagonists. Risk X: Avoid combination
Vincristine+Cardiac Glycosides(digoxin): Antineoplastic Agents may decrease the
absorption of Cardiac Glycosides. This may only affect digoxin tablets. Exceptions:
Digitoxin. Risk C: Monitor therapy
Procarbazine+ Sympathomimetic agents, tricyclic anti-depressants, tyramine-rich foods, ginseng,
levodopa, MOA and COMT inhibitors (see Procarbazine in patient information Headache, flushed
face, palpitations, rise in blood pressure mechanism: Procarbazine is a weak MAO inhibitor

Procarbazine+ Drugs which should not be used with MAOI Increased toxicity of these agents
Procarbazine+ CNS depressants Potentiation of CNS depression

61 Page 27 of
IL-2 + Hypotensive Agents: May enhance the adverse/toxic effect of other
Hypotensive Agents. Risk C: Monitor therapy
Interleukin-2 (IL-2) + doxorubicin have synergistic antitumor activity
IL-2 + aminoglycosides Concurrent administration of drugs possessing nephrotoxic
(e.g., aminoglycosides, indomethacin), myelotoxic (e.g., cytotoxic chemotherapy),
cardiotoxic (e.g., doxorubicin) or hepatotoxic (e.g., methotrexate, asparaginase) effects
with Proleukin may increase toxicity in these organ systems. The safety and efficacy of
Proleukin in combination with any antineoplastic agents have not been established.
IL-2 + methotrexate hepatotoxic (e.g., methotrexate, asparaginase) effects with
Proleukin may increase toxicity in these organ systems. The safety and efficacy of
Proleukin in combination with any antineoplastic agents have not been established.
IL-2 + L-asparaginasehepatotoxic (e.g., methotrexate, asparaginase) effects with
Proleukin may increase toxicity in these organ systems. The safety and efficacy of
Proleukin in combination with any antineoplastic agents have not been established.
IL-2 + glucocorticoids Glucocorticoids suppress the cell-mediated immunity. They
act by inhibiting genes that code for the cytokines IL-1, IL-2, IL-3, IL-4, IL-5, IL-6,
IL-8 and IFN-, the most important of which is IL-2. Smaller cytokine production
reduces the T cell proliferation.
IL-2 + narcotic analgesics Proleukin may affect central nervous function. Therefore,
interactions could occur following concomitant administration of psychotropic drugs
(e.g., narcotics, analgesics, antiemetics, sedatives, tranquilizers).
IL-2+ Benzodiazepines Proleukin may affect central nervous function. Therefore,
interactions could occur following concomitant administration of psychotropic drugs
(e.g., narcotics, analgesics, antiemetics, sedatives, tranquilizers).
Paclitaxil+cisplatin: Taxane Derivatives: Platinum Derivatives may enhance the
myelosuppressive effect of Taxane Derivatives. Administer Taxane derivative before
Platinum derivative when given as sequential infusions to limit toxicity. Risk D:
Consider therapy modification
Altretamine+cimetidine: Cimetidine Potentially increased half-life and toxicity of
altretamine1 21
6-MP+ allopurinol: Allopurinol: May decrease the metabolism of Mercaptopurine.
Risk D: Consider therapy modification
Asparaginase+ MTX Prevention of Methotrexate Cytotoxicity by Asparaginase
Inhibition of Methotrexate Polyglutamate Formation

Teniposdie+MTX
Teniposide (VM-26) can increase intracellular methotrexate (MTX) and its
polyglutamate derivatives in vitro and thus has the potential to improve the
therapeutic index of regimens containing MTX
Etoposide+Warfarin:

61 Page 28 of
Vitamin K Antagonists (eg, warfarin): Antineoplastic Agents may enhance the
anticoagulant effect of Vitamin K Antagonists. Antineoplastic Agents may diminish
the anticoagulant effect of Vitamin K Antagonists. Risk C: Monitor therapy
Vitamin K Antagonists (eg, warfarin): Etoposide may enhance the anticoagulant effect
of Vitamin K Antagonists. Risk C: Monitor therapy

141. Supportive treatment in cancer patients

Nausea and vomiting

Anticipatory emesis

Neutropenia

Febrile neutropenia

Behavioral therapy involving systematic desensitization

can be helpful in managing anticipatory emesis. Also,
benzodiazepines appear to be useful. However, the best
approach to anticipatory emesis is prevention, which
underscores the need to provide the most effective and
appropriate antiemetic regimens with the initial course
of emesis producing chemotherapy.
Three approches
*delay or reduce the drugs
*administer prophylactic antibiotics
* give haematopoietic growth factors or myeloid
growth factors in a prophylactic strategy.

61 Page 29 of

Extravasation

Mucositis

Stop the injection/infusion. Disconnect the

intravenous tubing.
_ Withdraw as much of the drug as possible,
via existing cannula or central venous
access device
(CVAD).
_ Mark area of skin with indelible pen. Take a
photograph of the area as soon as possible.
(Cameras are often available from Accident
& Emergency departments)
_ If appropriate, remove the peripheral
cannula (do not remove the CVAD).
_ Open extravasation kit (see Appendix B for
list of contents).
_ Refer to Appendix C to establish: whether
a hot pack or cold pack should be used, or
whether
neither is required; and what further
treatment is recommended. Follow guidance
in flow chart
below accordingly.
_ Note that for Neutral drugs, neither a cold
pack nor a hot pack is required. Aspirate as
much
fluid as possible, and then remove the
peripheral cannula. No further treatment
should be
required. Manage the situation
symptomatically. Document the incident in
the patients notes.
_ Inform patients Consultant oncologist /
haematologist (or SpR if Consultant not
available)
1. Improvement of oral care
2. Mucosal sparing radiation therapy technique
3. Mucositis pain control :The use of aspirin
mucilage and xylocaine viscous gurgle and oral
rinse are being used in practice in mucositis
related pain.

61 Page 30 of

Tumor lysis syndrome

Nephrotoxicity

4. Infection control. the use of topical antibiotic

lozenge containing polymyxin-B, tobramycin
and amphotericin-B reduced oral mucositis due
to radiotherapy (20, 21). Chlorhexidine
mouthwash too shown to reduce oral mucositis
5. Anti-inflammatory agents: Benzydamine, a nonsteroidal anti-inflammatory agent that inhibit
TNF-a, shown to be effective to control oral
mucositis and pain due to radiotherapy (29).
6. Reactive Oxygen Species (ROS) inhibitors.
ROS production is the first step of initiation of
mucositis following radiotherapy and
chemotherapy. Hence inhibition of the ROS
could be a promising option of mucositis
prevention. Amifostine; a thiol compound and a
potent ROS scavenger found effective to prevent
DNA damage following radiotherapy.
7. Salivary function modifiers: Some of the
chemotherapeutic agents secreated through
saliva leading to mucositis. Etoposide and 5fluorouracil are known to secreate through
saliva. Propanthelin, an anti-cholinergic agent
has been shown to reduce oral mucositis among
patients receiving etoposide chemotherapy.
8. Topical agents
9. Laser therapy
10. Growth factors.
Empirical guidelines recommend the use of topical
dimethylsulfoxide (DMSO) and cooling after
extravasation of anthracyclines or mitomycin, locally
injected hyaluronidase after extravasation of vinca
alkaloids, and locally injected sodium thiosulfate
(sodium hyposulfite) after extravasation of
chlormethine (mechlorethamine; mustine). Plastic
surgery may be necessary when conservative treatment
fails to prevent ulceration. The possibility of late local
reactions must also be considered in the management of
patients receiving chemotherapy.
recommended dose modifications in patients with renal
insufficiency

61 Page 31 of

142.TOXICITIES

OF SOME ANTI-CANCER DRUGS

61 Page 32 of

Drugs

Important Adverse Effects

Cyclophosphamide Acute hemorrhagic cystitis.

Methotrexate
Kidney damage, pulmonary fibrosis,
hepatotoxicity & stomatitis.
Hypersensitivity & peripheral
Paclitaxel
neuropathy
Nephrotoxicity, severe emesis,
neurotoxicity & ototoxicity.
Cisplatin
Ifosfamide
Acute hemorrhagic cystitis
Asparaginase
Coagulation deficiencies, liver injury,
hypersensitivity reactions
Doxorubicin
Cardiotoxicity (cardiomyopathy)
Bleomycin
Vincristine

Interferon
Interleukin-2
Flutamide
Leuprolide

Irinotecan
Tamoxifen
Trastuzumab

Fatal lung toxicity

Peripheral neurotoxicity
Flu like syndrome, dizzness, diarrhea,
anorexia, wt loss, abdominal pain,
thyroid dysfunction and depression
Capillary leak syndrome
Hepatotoxicity, gynecomastia &
diarrhea
Initial flare of prostate symptoms
Acute cholinergic syndrome (diarrhea,
abdominal cramps, increased
secretions)
Thromboembolism & increased risk of
endometrial carcinoma
Hypotension, flushing,
bronchconstriction, skin rash &
sensitizes patients to cardiotoxicity.

143.
Pharmaceutical Care & Pharmacotherapy Workup
1. the two arms of leukemia are :

61 Page 33 of

a.

Lymphoid /Myeloid

b.
2. which of the following is good prognosis for ALL
a. MLL rearrangement b. Hyperdiploidy
3. The lymphoid arm produces

b. Hyperdiploidy

a. b.

B and T cells

4. Principles of treatment of leukemia based on St.

Jude total XV are
a.

a. To avoid over- or under-treatment, immunologic and molecular assays are

used to measure the level of minimal residual leukemia after remission induction
to increase the precision of risk-directed therapy.
b. Pharmacodynamic and pharmacogenetic principles will be applied to optimize
therapy.

b.
c.

c. Cranial irradiation and epipodophyllotoxins are omitted in all but a very few
high-risk cases to prevent the development of therapy-related brain tumor and
acute myeloid leukemia.

5. Another name for BCR-ABL fusion gene is

__________chromosome
Philadelphia
6. The drug targeting BCR/ABL fusion gene is
_________________
Imatinib

7. ALL stands for _______________

Acute lymphocytic leukemia

8. ALL treatment phases includes

Induction/remission
Consolidation /

Phase /Goal
9. Intrathecal chemotherapy
_______________________

is

used

for

Continuation/

10. A patient is taking Enoxeprine for coagulopathy CNS prophylaxis

and his due to receive his intrathecal
after tomorrow ,what instructions should the
pharmacists tell the patient?
Should stop enoxeprine 24 hrs before procedure
144.
1. TPMT is the enzyme metabolizing _____________to its inactive form
2. Purinethol is a drug used in treatment of ___________________
3. When should a patient take Purinethol?

61 Page 34 of
4. Asparaginase MEDAC is ____potency of Asparaginase MERK
5. Methotrexate has a high Vd,what should we look for in the patient
6. Methotrexate is >90% plasma protein bound which lab should we
follow
7. The three important P450 Cytochrome include
a.
b.
8. c.
9. In tumor lysis syndrome the following lab values are increased
a.
b.
c.
10. In tumor lysis syndrome the following lab values are decreased
a.
11. Increase in PH with alkalnization will affect Allantoin solubility T-F
12. 25% of AML patients will have _______ gene mutation
13. ATRA is used to _______________APL cells
14. Dexamethasone is used for Brain tumor patients during
ChemotherapyT-F
15. Three most common pediatric cancers include
a.
b.
c.
16. CD20 is targeted by _____________________
17. PCP prophylaxis is done by ___________________
18. If the patient has deficient G6PD we can give Sutrim T-F

145. Patient Counseling

1- Itraconazole administration:
*Capsule form:
- Doses 300 mg: given once daily in the middle of lunch, with apple, orange or lemonade
juice (acidic beverage) (q 24 hours at the same time each day).

61 Page 35 of
-

Doses > 300 mg: divide every 12 hours in the middle of food, with apple, orange or
lemonade juice (acidic beverage) (the patient will be old enough to be convinced to eat
well with each dose).
*Syrup form:
- Preferably divide every 12 hours on empty stomach (1 hr before or 2 hrs after food).

2- Itraconazole most possible interactions at the day care unit:

*The following applies only on the capsule form (not the syrup form):
- Antacids, Calcium carbonate & Potassium bicarbonate (sachets): separate them at least 6
hrs before Itraconazole capsules and at least 2 hours after Itraconazole.
- Proton pump inhibitors (as Pantoprazole or Esomeprazole): DO NOT GIVE PPIs with
Itraconazole capsules, switch to minimal dose of Ranitidine (2 mg/kg once daily at
bedtime).
*The following applies on all forms of Itraconazole (capsule & syrup form):
- Multivitamins, minerals & Iron: separate them at least 6 hrs before Itraconazole & at least
3 hours after Itraconazole.
*Chemotherapy & Itraconzole:
- Patients on Total XV protocol:
Itraconazole will be stopped for 3 days: 48 hrs before & 48 hrs after doses of:
Vincristine, Doxorubicin & Cyclophosphamide.
i.e.: If the patient is due to a week that contains any of the above at 10/8 for
example, he will skip Itraconazole at 9/8, 10/8 & 11/8 and continue on 12/8 as
usual.
Itraconazole will be given safely with weeks of methotrexate/6mp or
asparaginase/6mp only.
GIVE THE PARENTS A COPY OF THE ROAD MAP: mark the weeks at
which Itraconazole will be held, educate the parents when to hold and when to
resume Itraconazole, revise with them at each visit. Tell them this is TO
DECREASE CHEMOTHERAPY SIDE EFFECTS.
- Patients on other protocols:
Itraconazole should be held with all chemotherapy EXCEPT: 6-mp, 6thioguanine, Asparaginase, Cytarabine, Carboplatin, Cisplatin, Flurouracil &
weekly low-dose Methotrexate (IM or PO). Consult the DIC for further
information.
Itraconazole will be held at least 48 hrs before the chemotherapy course (or
longer) and at 24-48 hrs after, (according to half lives of the last-day
chemotherapy).
EDUCATE THE PARENTS TO HOLD ITRACONAZOLE 2 DAYS
BEFORE EACH COURSE.

3- Voriconazole administration & Interactions:

-

Given 1 hour before or 2 hours after meals.

Interactions with chemotherapy: the same as Itraconazole but separate it just 12-24 hrs
before and 24-36 hours after chemotherapy.

4- Enoxaparin (Clexane) precautions in the day care unit:

-

Do NOT administer into upper arms (just to avoid administering it intramuscularly).

Administer by deep subcutaneous injection between the left and right anterolateral and
left and right posterior abdominal.
Hold Enoxaparin for INTRATHECALS: Give last dose 24-48 hours prior to procedure.
Restart 24 hours after the procedure. YOU MAY GIVE THE PARENTS A COPY OF
THE ROAD MAP: mark the weeks at which Enoxaparin will be held. Or YOU MAY
JUST HIGHLIGHT THAT IF THE PATIENT WILL BE FASTING FOR AN ITH, thats
when Enoxaparin should be held.

61 Page 36 of
5- Miscellaneous precautions for the patients:
-

Separate Ciprofloxacin oral from antacids, calcium salts, Iron salts (like in
multivitamins) at least 6 hrs before Ciprofloxacin and at least 2 hours after Ciprofloxacin.
Ciprofloxacin: 1 hr at least before meals. Avoid direct sunlight, & drink plenty of fluids.
Separate Ursodiol (Ursofalk, Ursogall) from aluminum containing antacids at least 6 hrs
before Ursodiol and at least 2 hours after Ursodiol.
Separate Dexamethasone oral from antacids, calcium carbonate at least 2 hrs before and
after.
Sutrim: shake well & refrigerate for 2 weeks (if suspension), drink plenty of fluids.
Sutrim: Separate the three days of prophylaxis from IM or oral Methotrexate by 48 hrs,
Ex: If the patient is taking methotrexate at Thursday, tell him to take Sutrim at Sunday,
Monday & Tuesday.
Cyclo & Ifosfamide: Void urine frequently (every 2 hrs), drink fluids & report any
burning sensation.
Carboplatin is always BEFORE Etoposide & Cyclophosphamide is always BEFORE
Doxorubicin.

6- General regulations in the day care unit:

1- If a course has begun at a date other than when it was written, please write clearly in
file when was day 1, to prevent errors afterwards.
2- Check the delivered continuing I.V. medications with the charge nurse 1 hour before
your shift ends, if there are patients that did not come for their medications, get their
phone numbers from CERNER & call them right away to get them coming.
3- Same thing for oral medications, call the parents who left their medications at the
same day or right at the next day.
4- Always be careful with the NEW ONES (like week 1 continuation Total XV,
induction of TXV, day 22, week 1 of any protocol) these are at high risk of forgetting,
missing & errors. They should be educated slowly & carefully.
5- Also be careful with 1st times (1st time 6-mp together with dexa at week 72
continuation SR, 1st time delivering IM methotrexate for the NEXT week, NOT
TODAY).
6- When a pharmacist in the outpatient clinic writes before his signature: Patient is on
drugs. You should revise with the parents, the names of these
medications, are they taking them regularly or not, when will they have follow ups &
are the amount of these medications with them sufficient till the next follow up or
not.

147.

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148. Concomitant administration of Itraconazole will increase the toxicity of the
following except:
A) DoxorubicinB) VincristineC) CyclosporineD) Cytarabine
149.The following medications cannot be safely coadministrated with HDMTX
except:
A) PhenytoinB) TazocinC) AmphotericinB D) Ceftazidime
150.G.N a case of B.T maintained on Valproic acid and Carbamazepine as
anticonvulsants now she is stable and no convulsions since 3 months but the trough
total Carbamazepine level is 1 mcg / ml. It was recommended by a pharmacist to
increase the dose 3 folds at least to obtain a level 3mcg / ml.
After the dose increase by 7 days the patient admitted with CV, hepatic and GIT
complications. A new level was obtained and it was 6 mcg / ml.
IN your opinion: The pharmacist was right or wrong in her recommendation and
why?
151. Increase in Cyclosporine trough level is expected when coadministrated with the
following except:
A) VoriconazoleB) ItraconazoleC) RifampicinD) Phenytoin
E) C + DF) B + D
152.Itraconazole should to be stopped with the following Chemotherapy except:
A) CytarabineB) VincristineC) EtoposideD) Doxorubicin
E) A + DF) B + D
153. It is recommended to change the Vancomycin dose according to peak levels not
trough from the efficacy point of view T F

61 Page 40 of
154.

1. What is missing from this physician order?

2. In which treatment phase is the patient now?

61 Page 41 of
155.

What is the importance of D15 for the treatment decision?

156.

Why methylprednisolone is replacing Predsol forte?

What is the difference e between Predsol and Predsol forte?

Why is Zyloric prescribed ?

157.

What is the drug this patient should take for the diagnosis written ?

61 Page 42 of
158.

What is different between 1st and 2nd ADE?

159.

1. Why is Vancomycin added?Why is the Infusion over 11/2?

61 Page 43 of
160.

Why is Voriconazole used ?

What is the difference between daunorubicin and doxorubicin?

61 Page 44 of

161. Evidence based practice (EBP) is

a. the thorough, concise, and sensible use of the current best evidence in
making decisions about the care of individual patients
b. intuition based
c. unsystematic clinical experience,and pathophysiologic rationale as sufficient
grounds for clinical decision-making,
162.Evidence-based medicine puts less emphasis on:
a.intuition,
b.unsystematic clinical experience,and pathophysiologic rationale as sufficient
grounds for clinical decision-making,
c a and b
163.Evidence base practice considers:
a. The benefits and risk of other patient management strategies,
b. the role of patients values and preferences in trading off those benefits and
risks.
c. a and b
164.The new view to managing the overload of information
a.How do I keep up with new developments in medicine?
b.What developments in medicine do I need to keep up with?
c. all of the above
d. none of the above
165.The steps to Evidence Based Practice are
a.What is the question?
b.How do I find the evidence?
c.Are the methods valid?
d.What are the results?
e.All of the above

166.Chemotherapy in ALL include

a.Cisplatin
b.Taxol
c.Vincristine
d.Dexamethasone
e. c and d

167.Prognosis is
e.
f.
g.
h.

the prior knowledge of outcome of a disease

the increase in intensity of therapy
All of the above
None of the above

168.In Acute lymphoblastic leukemia a child with 12 years will be

e.
f.
g.
h.

Bad prognosis
Good prognosis
Not a prognostic factor
None of the above

169. The gene function is expression of

e.
f.
g.
h.

Proteins
Chromosomes
All of the above
None of the above

170.Asparaginase is
e. an enzyme that catalyzes the hydrolysis of asparagine to
aspartic acid
f. an anticancer alkylating agent
g. All of the above
h. None of the above

61 Page 45 of

171. Storage of Asparaginase Medac

e.
f.
g.
h.

Must be in the refrigerator

Can be in Room temperature
All of the above
None of the above

172.Calculating a dose of Asparaginase Medac 10000 international units in a 0.8 m2

child will be
d. 4000 international units
e. 8000 international units
f. None of the above

173.The term of dose intensity (DI) is used to define

d.
e.
f.

the drug dose delivered per time unit and is expressed as mg/m2 per week
the patient ideal body weight
the protocol identified dosage form

174.The mechanism of resistance to methotrexate is

d.

decreased uptake of dihydrofolate

f.

a and b

e. increased dihydrofolate reductase (DHFR) activity

175.Total XV: Strategies to Decrease Toxicities
Eliminate cranial irradiation
Limit the cumulative dose of
Limit the cumulative dose of cyclophosphamide

176.Methotrexate inside the cell will be converted to

a.
b.
c.
d.

Polyglutamate form ,7 isomers

Acetate form , 7 isomers
All of the above
None of the above

177.TPMT is responsible for

a.
b.
c.
d.

Inactivation of 6MP
Activation of 6MP
All of the above
None of the above

178.Heterozygocity means Loss of heterozygosity (LOH) in a cell represents

a.
b.
c.
d.

the loss of normal function of one allele of a gene

the loss of normal function of two alleles of a gene
All of the above
None of the above

179.Polymorphism in TPMT will cause

a. Accumulation of active drug causing toxicity
b. Increasing the metabolism of the active drug reducing the
effectiveness
c. All of the above
d. None of the above

61 Page 46 of

180.The Intrathecal therapy is given to

e.
f.
g.
h.

CNS prophylaxis
Systemically increase the level of methotrexate
All of the above
None of the above

181.Methotrexate ,Cytosar and Hydrocortisone

d. Can be given together as intrathecal injection
e. Drug drug interaction prevent co-administration
f. None of the above

182.Vincristine
d. Is Fatal if given intrathecally
e. Is only given intrathecally
f. None of the above

183. Pharmaceutical Care & Pharmacotherapy Workup

61 Page 47 of
1. Causes for mortality and morbidity of children n the developing world are
ranked as
follows :
( ) Accidents
( ) Malnutrition
( ) Malaria
( ) Respiratory Infections
( ) HIV
( ) Cancer
2. Leukemogenesis concerns
a.
b.
c.
3. the two arms of leukemia are :
a.
b.
4. which of the following is good prognosis for ALL
a. MLL rearrangement b. Hyperdiploidy
5. Determinant of treatment response include
a.
b.
c.
d.
6. The lymphoid arm produces
a. b.
7. Principles of treatment of leukemia based on St. Jude total XV are
a.
b.
c.
8. Another name for BCR-ABL fusion gene is __________chromosome
9. The drug targeting BCR/ABL fusion gene is _________________
10. ALL stands for _______________
11. ALL treatment phases includes
Phase
Goal

12. Intrathecal chemotherapy is used for _______________________

61 Page 48 of
13. A patient is taking Enoxeprine for coagulopathy and his due to receive his
intrathecal
after tomorrow ,what instructions should the pharmacists tell the patient?
14. TPMT is the enzyme metabolizing _____________to its inactive form
15. Purinethol is a drug used in treatment of ___________________
16. When should a patient take Purinethol?
17. Asparaginase MEDAC is ____potency of Asparaginase MERK
18. Methotrexate has a high Vd,what should we look for in the patient
19. Methotrexate is >90% plasma protein bound which lab should we follow
20. The three important P450 Cytochrome include
a.
b.
c.
21. In tumor lysis syndrome the following lab values are increased
a.
b.
c.
22. In tumor lysis syndrome the following lab values are decreased
a.
23. Increase in PH with alkalnization will affect Allantoin solubility T-F
24. 25% of AML patients will have _______ gene mutation
25. ATRA is used to _______________APL cells
26. Dexamethasone is used for Brain tumor patients during Chemotherapy
T-F
27. Three most common pediatric cancers include
a.
b.
c.
28. CD20 is targeted by _____________________
29. PCP prophylaxis is done by ___________________
30. If the patient has deficient G6PD we can give Sutrim T-F

7- Itraconazole administration:

61 Page 49 of
*Capsule form:
- Doses 300 mg: given once daily in the middle of lunch, with apple, orange or lemonade
juice (acidic beverage) (q 24 hours at the same time each day).
- Doses > 300 mg: divide every 12 hours in the middle of food, with apple, orange or
lemonade juice (acidic beverage) (the patient will be old enough to be convinced to eat
well with each dose).
*Syrup form:
- Preferably divide every 12 hours on empty stomach (1 hr before or 2 hrs after food).

8- Itraconazole most possible interactions at the day care unit:

*The following applies only on the capsule form (not the syrup form):
- Antacids, Calcium carbonate & Potassium bicarbonate (sachets): separate them at least 6
hrs before Itraconazole capsules and at least 2 hours after Itraconazole.
- Proton pump inhibitors (as Pantoprazole or Esomeprazole): DO NOT GIVE PPIs with
Itraconazole capsules, switch to minimal dose of Ranitidine (2 mg/kg once daily at
bedtime).
*The following applies on all forms of Itraconazole (capsule & syrup form):
- Multivitamins, minerals & Iron: separate them at least 6 hrs before Itraconazole & at least
3 hours after Itraconazole.
*Chemotherapy & Itraconzole:
- Patients on Total XV protocol:
Itraconazole will be stopped for 3 days: 48 hrs before & 48 hrs after doses of:
Vincristine, Doxorubicin & Cyclophosphamide.
i.e.: If the patient is due to a week that contains any of the above at 10/8 for
example, he will skip Itraconazole at 9/8, 10/8 & 11/8 and continue on 12/8 as
usual.
Itraconazole will be given safely with weeks of methotrexate/6mp or
asparaginase/6mp only.
GIVE THE PARENTS A COPY OF THE ROAD MAP: mark the weeks at
which Itraconazole will be held, educate the parents when to hold and when to
resume Itraconazole, revise with them at each visit. Tell them this is TO
DECREASE CHEMOTHERAPY SIDE EFFECTS.
- Patients on other protocols:
Itraconazole should be held with all chemotherapy EXCEPT: 6-mp, 6thioguanine, Asparaginase, Cytarabine, Carboplatin, Cisplatin, Flurouracil &
weekly low-dose Methotrexate (IM or PO). Consult the DIC for further
information.
Itraconazole will be held at least 48 hrs before the chemotherapy course (or
longer) and at 24-48 hrs after, (according to half lives of the last-day
chemotherapy).
EDUCATE THE PARENTS TO HOLD ITRACONAZOLE 2 DAYS
BEFORE EACH COURSE.

9- Voriconazole administration & Interactions:

-

Given 1 hour before or 2 hours after meals.

Interactions with chemotherapy: the same as Itraconazole but separate it just 12-24 hrs
before and 24-36 hours after chemotherapy.

10- Enoxaparin (Clexane) precautions in the day care unit:

-

Do NOT administer into upper arms (just to avoid administering it intramuscularly).

Administer by deep subcutaneous injection between the left and right anterolateral and
left and right posterior abdominal.
Hold Enoxaparin for INTRATHECALS: Give last dose 24-48 hours prior to procedure.
Restart 24 hours after the procedure. YOU MAY GIVE THE PARENTS A COPY OF

61 Page 50 of
THE ROAD MAP: mark the weeks at which Enoxaparin will be held. Or YOU MAY
JUST HIGHLIGHT THAT IF THE PATIENT WILL BE FASTING FOR AN ITH, thats
when Enoxaparin should be held.

11- Miscellaneous precautions for the patients:

-

Separate Ciprofloxacin oral from antacids, calcium salts, Iron salts (like in
multivitamins) at least 6 hrs before Ciprofloxacin and at least 2 hours after Ciprofloxacin.
Ciprofloxacin: 1 hr at least before meals. Avoid direct sunlight, & drink plenty of fluids.
Separate Ursodiol (Ursofalk, Ursogall) from aluminum containing antacids at least 6 hrs
before Ursodiol and at least 2 hours after Ursodiol.
Separate Dexamethasone oral from antacids, calcium carbonate at least 2 hrs before and
after.
Sutrim: shake well & refrigerate for 2 weeks (if suspension), drink plenty of fluids.
Sutrim: Separate the three days of prophylaxis from IM or oral Methotrexate by 48 hrs,
Ex: If the patient is taking methotrexate at Thursday, tell him to take Sutrim at Sunday,
Monday & Tuesday.
Cyclo & Ifosfamide: Void urine frequently (every 2 hrs), drink fluids & report any
burning sensation.
Carboplatin is always BEFORE Etoposide & Cyclophosphamide is always BEFORE
Doxorubicin.

12- General regulations in the day care unit:

7- If a course has begun at a date other than when it was written, please write clearly in
file when was day 1, to prevent errors afterwards.
8- Check the delivered continuing I.V. medications with the charge nurse 1 hour before
your shift ends, if there are patients that did not come for their medications, get their
phone numbers from CERNER & call them right away to get them coming.
9- Same thing for oral medications, call the parents who left their medications at the
same day or right at the next day.
10- Always be careful with the NEW ONES (like week 1 continuation Total XV,
induction of TXV, day 22, week 1 of any protocol) these are at high risk of forgetting,
missing & errors. They should be educated slowly & carefully.
11- Also be careful with 1st times (1st time 6-mp together with dexa at week 72
continuation SR, 1st time delivering IM methotrexate for the NEXT week, NOT
TODAY).
12- When a pharmacist in the outpatient clinic writes before his signature: Patient is on
drugs. You should revise with the parents, the names of these
medications, are they taking them regularly or not, when will they have follow ups &
are the amount of these medications with them sufficient till the next follow up or
not.

) (

1
:
) :
:

61 Page 51 of
.1 ) (
(
.2 )
.3 ) (
.4 ) (
.5 ) (
.6 ) (
.7 ) (
.8 ) (
.9 ) (
. 10 ) (
.11 ) (
.12 ) (
.13 ) (
.14 ) (
: :
.1 :
.1 .2 .3

.2
.1 .2 .3 123 .4
.3 :
.1 .2 .3
.4
:
.1 .2 . 3
.4 :
.1 . 2 . 3
.5 :
.1 .2 .3%5/
.6 :
s-creatinine .1
ALT .2
AST .3
.7 :
.1
.2
.3
.8
:
.3
.2
.1
.6
.5
.4
.9 :
.1
.2
.3
123 .4
12 .5
Sarcomas . 11
.1

61 Page 52 of
.2
.3
123 .4
Carcinomas .12
.1
.2
.3
123 .4
Lymphomas and Leukemias .13
.1
.2
.3
123 .4
: :
.1
.1
.2
.3
.4
.2
.1
.2
.3
.4
.5
.6
.3

.4 150
%0.9

.5 250 /
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.7 :
.1
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.8
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.9 70 165
:
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100 / 2
400/ 2
1200 / 2

61 Page 53 of

Exam
When the goal of chemotherapy is control or palliation, the purpose of treatment
is to:
a. totally eliminate the tumor
b. manage symptoms caused by tumor
c. improve quality of life
d. reduce tumor size
DNA synthesis occurs in which phase of the cell cycle?
a. G1
b. S
c. G2
d. M
Prophase, metaphase, anaphase and telophase occur in which phase of the cell
cycle?
a. G1
b. S
c. G2
d. M
long term use of single agent chemotherapy has been found to:
a. achieve long term remission
b. cause lethal toxicities
c. induce allergies in patients
d. result in drug resistant
Principles followed when combining chemotherapeutic agents include:
a. The agents should have the same mechanism of action
b. The agents should have minimal overlapping toxicity
c. The agents should be antagonistic
d. Each agent should be effective alone against the tumour
Adjuvant chemotherapy is the use of chemotherapy:
a. Prior to surgery
b. To eliminate micro-metastasis
c. In conjunction with radiation therapy
d. To eliminate pain cause by the tumour
Chemotherapy effectiveness is influenced by:
a. Drug selection
b. drug scheduling
c. Patient age

61 Page 54 of
d. Patient age

Place an (S) if the drug classification is cell cycle specific and (N) if the
classification is cell cycle nonspecific:
1. alkylators
2. antimetabolites
3. antitumor antibiotics
4. plant alkaloids
5. hormones
6. miscellaneous agents
Match between column A and B
Column A
Column B
Drug classification
Mechanism of action
1. 1.alkylators
a. unknown mechanism of action
2. antimetabolites
b. causes abnormal linking of DNA base pair
3. antitumor antibiotics c. alters cellular environment
4. plant alkaloids
d. substitutes for natural metabolites
5. hormones
e. binds or reacts with DNA
6. miscellaneous agents
f. binds to microtubular proteins during
An example of combination chemotherapy is FAC answer the following:
1. drugs used in this Protocol
2. the drug classification(s) utilized in this protocol
3. the portion of the cell cycle affected by the drugs utilized by this protocol
4. use of this protocol
5. doses for each drug
6. administration of drugs and order of administration
7. differences between 5-FU iv-shot and infusion
8. explain the significant of Vd
9. Dose limiting toxicity
10. supportive care
Complete
1. neoadjuvant treatment is _______________________________________
2. The three goals of chemotherapy are 1.
2.
3.
3. A cure occurs when malignant cells are _____________________.
4. The administration of two or more chemotherapy agents is known as___________.
5. One mechanism by which tumor cells become resistant to chemotherapy drugs is
through the cell surface protein called ______________________, which acts as a
pump and remove the drug from inside the cell before the cell is destroyed.
6. Radiation recall reaction is _____________________________________________
and is caused by _______________________________________________________
7. A syndrome is _______________________________________________________
8. Auto oxidation occur with ____________________
9. Dose limiting toxicity of chemotherapy is _________________________________
10. Mesna is used for ___________________________________________________

61 Page 55 of
11. Leucovorin is used before 5Fu to____________________________________
and after MTx as _______________________________.
12. VCR side effects include 1. _____________2._____________ 3._______
13. Adverse prognostic factors in node ve Breast patients are

14. CMF: Bonadonna Protocol Cyclophosphamide: ______ mg/m2, po daily x 14

days Methotrexate: -__________mg/m2, iv, days 1 & 8 5-Fluorouracil:
___________ mg/m2, iv, days 1 & 8
15.Treatment schedule: q___________weeks .For adjuvant therapy, a total of
__________cycles is prescribed ,Hematological parameters: ANC_________;
platelets__________ .Standard antiemetics, e.g.: metoclopramide ______mg po,
Gravol 50 mg po .Consider supporting with G-CSF in face of prolonged
_____________ .Encourage fluid intake of at least _____/day to minimize both
____________ toxicity as well as impact of ________________________ on bladder
16.In CMF Variants (1) Consider ________ antagonists for antiemetic prophylaxis
17.AC: Adriamycin: _______ mg/m2, iv Cyclophosphamide _______ mg/m2, iv
18.Treatment schedule: q_______weeks .Total of ______ cycles, for adjuvant therapy
Haematological parameters: ANC ____________; platelets:____________ Consider
nadir CBC at day ___________Antiemetic prophylaxis: ___________ antagonists
+________________
19.CEF: Adjuvant Therapy in Node +ve Breast Carcinoma
20.Cyclophosphamide _______mg/m2, po x 14 days Epirubicin ______________
mg/m2, iv, days 1 & 8 5-Fluorouracil ___________ mg/m2, iv, days 1 & 8
21.Treatment schedule: q_______weeks, for total of _________cycles . G-CSF
support, as indicated, to avoid ______________________
22.IV FAC/FEC 5-Fluorouracil _________mg/m2, iv Adriamycin/Epirubicin
_______mg/m2, iv Cyclophosphamide __________mg/m2, iv
23.Second and Third-Line Chemotherapy in Advanced Breast Carcinoma is
_________________ 100 mg/m2, iv over 1 hour
24. Taxotere Mandatory premedication with __________ 8 mg bid x 5 days, starting
24 hours prior to taxotere. Chemotherapy cannot be given without this.
25.Navelbine Navelbine ________ mg/m2, iv, days 1, 8 & 15
26.Capecitabine Capecitabine ___________mg/m2/day, divided into 2 doses x 14
days, po

61 Page 56 of
27.DLT is _____________ which may be severe .Caution regarding possible
development of __________________syndrome. Treatment with pyridoxine 50 mg
tid, po.

Q by patients :
1. How is chemotherapy is given? The drugs can be delivered to our circulatory
system by many different routes:

2. How will I know if the chemotherapy is working? There are several ways to tell
if a tumor is responding to treatment.

3.Corticosteroids: Cortisol (hydrocortisone) and cortisone: these are__________

occurring corticosteroids. Other corticosteroids are synthetic: Examples include
fludrocortisone ,____________ ,prednisolone ,fluocortolone ,_______________ and
betamethasone.
4.Femara New Weapon In The Battle Femara (_________________)Femara, is
an______________________ inhibitor. ____________fuels the growth of about half
of all breast cancers, especially those in older women. Tamoxifen, the top hormonal
treatment for estrogen-fueled tumors. Commonly reported adverse events for Femara
vs. Tamoxifen were _______________. Femara may cause fetal harm when
administered to___________women. Tamoxifen has been linked to increases in
womens risk of _________________ cancer or blood clots.

61 Page 57 of

Extravasation:
1. Doxorubicin, daunorubicin, epirubicin and mitomycin bind to DNA, recycle locally
and may cause a progressive _________________ over several weeks, requiring
excision and skin grafting. In order to avoid problems of this kind, great care must be
taken to assure that these agents are given into an __________ vein with a good free
flow of blood. Drug may leak from sites of previous recent punctures or from veins
which are occluded from any cause such as tight clothing, obstructing masses or
clotting. Therefore, the insertion site should not be _______________ to a recent
venipuncture or in an arm with compromised circulation. It is preferable to select, if
possible, a ________vein which is not adjacent to a joint or structures which may be
particularly troublesome should a tissue slough occur (such as the wrist or hand).
2. Doxorubicin and epirubicin are particularly likely to cause a
____________________ (a histamine release phenomenon) which will subside but
may take thirty minutes or more after the injection is stopped. _____________
injected into the IV line may hasten clearing of the reaction, and requires a
physicians order. The injection may then be cautiously resumed.
Thrombosis or sclerosis of veins may occur due to the local effect of
chemotherapeutic agents on the endothelium. These can be managed conservatively
with ___________ compresses to the area plus an a_________for pain, if required.

3. Extravasation Tray contain

4. Procedure for the extravasation of a VESICANT wii be :

61 Page 58 of

5. Several mechanisms by which certain agents can cause tissue necrosis by

extravasation:
1
2
3
4
5
6. Medications that may cause extravasation1
2
3
4
5
6
7. Preventative Measures-how to prevent extravasation ?
1
2
3
4
5
6
7
8
9
10

61 Page 59 of

1. Apoptosis is ____________________________
2.Why should a cell commit suicide?
1.
2.
2.Blood is a liquid tissue. Suspended in the watery plasma are seven types of cells
and cell fragments:
1
2
3
4
5
6
7
3.five kinds of white blood cells (WBCs) or leukocytes
1
2
3
4
5
4.Three kinds of granulocytes
1
2
3
5. Two kinds of leukocytes without granules in their cytoplasm
1
2

61 Page 60 of
6. If one takes a sample of blood, treats it with an agent to prevent clotting, and spins
it in a centrifuge, the red cells _______________while the white cells ___________
forming the _________________.
The fraction occupied by the red cells is called the ____________. Normally it is
approximately 45%. Values much lower than this are a sign of anemia.
7. Functions of the blood is
1
2
8. All the various types of blood cells are produced in the ______________(some 1011
of them each day in an adult human!). arise from a single type of cell called a
_____________________.
9. A eukaryotic cell cannot divide into two, the two into four, etc. unless two
processes alternate:
1
2
10. the cell cycle consists of:
G1 =
S=
G2 =
M=
15. The p53 protein senses DNA damage and can halt progression of the cell cycle in
both G1 and G2. Both copies of the p53 gene must be mutated for this to fail so
mutations in p53 are recessive, and p53 qualifies as a ____________________ gene.
The p53 protein is also a key player in ____________, forcing "bad" cells to commit
suicide.

ORDER #1

Patient Identification:

Date of Order Time of

Order Today Now Hours

61 Page 61 of

1.

Smythe, Charlene

Change IV to:

20-461-24-1820

KCl 20 mEq in D5-1/2 NS

1000 ml

47 y.o. 146 lb

@ 125 ml/hr
NKA

Nursing Unit:
B

Room
No

Bed# 14

Snuffy Smith, MD

. What is the Liter concentration of Potassium Chloride?

Answer:
2. What is the total daily dose of Potassium Chloride that this patient will
receive?
Answer: