Maggie Charpentier PharmD BCPS Clinical Associate Professor University of Rhode Island Perdiem pharmacist Roger Williams Medical Center Goal and Objectives Goal Educate pharmacists regarding counseling and safe dispensing of oral chemotherapy in community pharmacy ID: 184769
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Slide1
Oral Chemotherapy – Moving Cancer Treatment into Community Pharmacy
Maggie Charpentier, PharmD, BCPS
Clinical Associate Professor University of Rhode Island
Per-diem pharmacist: Roger Williams Medical CenterSlide2
Goal and Objectives
Goal:
Educate pharmacists regarding counseling and safe dispensing of oral chemotherapy in community pharmacy
Objectives:
Review the changing paradigm of cancer treatment –moving to chronic therapy administered in the community
Review potential hazards of dispensing chemotherapy in the pharmacy
Review recommendations to safeguard pharmacy staff when dispensing
Review counseling points for patients and their care givers in safely administering and disposing of chemotherapy
Review counseling of oral chemotherapySlide3
Practice setting-pharmacists only
:10
1. Community pharmacy
2. Outpatient clinic
3. Hospital setting
4. Non – dispensing practice site
5. Other Slide4
Practice location-pharmacists
In RI or within 20 miles of RI
Outside RI and 20 miles surrounding area
:10Slide5
How confident are you about your oral chemotherapy knowledge?
Not confident
Somewhat confident
Neutral
Confident
Strongly Confident
:15Slide6
Does your pharmacy have a counting tray devoted to
cytotoxic
medications?
Yes
No
:10Slide7
Do you wear gloves when handling oral
cytotoxic
chemotherapy ?
Yes
No
:10Slide8
Do you usually wash hands immediately after handling oral
cytotoxic
medications?
Yes
No
:10Slide9
Do you counsel caregivers on safe handling of cytoxic
medication?
Yes
No
:10Slide10
Do you require a double-check by another person when dispensing oral
cytotoxic
medication?
Yes
No
:10Slide11
Which of the following oral chemotherapy agents is dosed based on Body Surface Area (BSA)?
:15
Sunitinib
Exemastane
temazolamide
I don’t knowSlide12
The wife of a patient calls your pharmacy. He can no longer swallow medications unless they are liquid, or crushed. Her husband is on
Temodar
. What is your response?
Tell the wife to place in a
ziplock
bag and hit with a
mallot
, then rinse into a cup of water to drink
Prepare a liquid formulation in pharmacy by crushing tablets and mixing with simple sugar syrup, giving a 30 day expirationCall the doctor
I don’t know
:30Slide13
What counseling point(s) is/are important for a patient receiving chemotherapy that can lower white blood counts?
Call your doctor for any temperature 2 degrees above your normal temperature
If you have symptoms of sore throat, or cough, call the doctor only if accompanied by a fever
Avoid contact with anyone who is ill.
All of the above
I
don’t know
:20Slide14
Counseling for capecitabine
(
Xeloda
®) includes which of the following?
Edema is common
Take within 30 minutes of a meal
Skin rash indicates higher efficacy
All of the above
I don’t knowSlide15
Which of the following drugs can interact with CYP 3A4 agents?
Erlotinib
(
Tarceva
®)
Sunitinib
(
Sutent
®)Lapatinib (Tykerb®)
All of the aboveI don’t know
:15Slide16
Which of the following drugs may commonly cause hypertension?
Temodar
®
Tarceva
®
Sutent
®
All of the above
I don’t know
:10Slide17
Oral Chemotherapy-coming to a pharmacy near you!
Traditionally – chemotherapy was rarely dispensed in the community pharmacy
Little or no data on safe practice
Some agents:
Busulfan
Capecitabine
Chlorambucil Cyclophosphamide Etoposide Hydroxyurea
Lomustine MelphalanMercaptopurine MethotrexateProcarbazine Thalidomide
Temozolomide targeted agents: imatinib
,
erlotinib
, etc
Hormonal agents:
tamoxifen
,
anastrozole
Slide18
Where are we headed?
Approximately 20-25% of investigational chemotherapy agents are oral
Annual growth: expected to be 30-35%
Patient preference
Advantages to patients
Challenges
Hematol Oncol News Issues 2007;6:24-6Slide19
Challenges – taken one-by-one
Medication errors
Wrong drug
Wrong dose
Wrong patient
Wrong directions
In hospitals – we follow written referenced protocols, verified using several sources, and checked by two pharmacists, technician, nurse, and physician.Slide20
Mo Lawsuit alleges [Chain Pharmacy] Error Caused Miscarriage
October 23, 2007
When
Chanda
Givens began feeling sick and throwing up about a month into her pregnancy, she wrote it off as morning sickness.
It was only after the suburban St. Louis woman miscarried a month later that she learned the pills that she thought were prenatal vitamins were actually a potent chemotherapy drug that killed her unborn child, according to a lawsuit against [PHARMACY]., whose pharmacy allegedly dispensed the wrong medicine.
Mefford
said Givens became pregnant in February. On March 6, she went to an O'Fallon, Mo., [PHARMACY] to fill a prescription for Materna
, a prenatal vitamin.Instead, Mefford said, Givens was given Matulane, a chemotherapy drug for treatment of Hodgkin's disease. The lawsuit states that drug is designed to interfere with cell growth and DNA development.Givens began feeling nauseous and vomiting soon after taking the drug. Later in March, her doctor warned the baby was not developing properly.Slide21
Medication errors documented in oral chemotherapy
Four clinics retrospectively reviewed medication errors in children and adult oncology patients
Occurred in 7.1% of adult clinic visits and 18.8% of pediatric clinic visits were associated with a medication error
Good news, study included all errors, of all the chemotherapy medications reviewed, 1.4% of chemotherapy prescriptions resulted in an error
7% of errors occurring in adults were during home administration; while 27% of pediatric errors were during home administration
J Clin Oncol 2009. 27: 891-96.Slide22
Types of errors
Dose adjustments not made based on clinical status changes (drop in
neutrophil
count, change in organ function)
Orders written for several months
In children, parents made errors in measurement, and administration
J Clin Oncol 2009. 27:891-96Slide23
Interventions identified to minimize errors
Improved communication
Improved technology
Computer order entry
EMAR
EMR
Drug dose double-checking
Patient education about home medication useIn children: educate parents, color-code syringe, or lines marking the syringe for dosingJ Clin Oncol 2009. 27:891-96Slide24
Overall, lack of data on errors for OC use at home
Few studies have evaluated the problem
Area of concern while more chemotherapy is being used at home
Highlights importance of education for patients, families, pharmacists, and oncology team
Literature generally indicates an error rate of 3-10% for chemotherapy related errors
Pharmacotherapy 2008; 28:1-13, Oncol Nurs forum 1999; 26:1033-42, Am J Health Syst Pharm 1996;53:737-46Slide25
What skills does the pharmacist need?
Proficient pharmacists should
Have appropriate knowledge of indications
Understand dosing and administration of oral chemotherapy
Aware of drug-drug interactions
Counsel patients on potential adverse events
Aware of special handling precautionsSlide26
Survey of community pharmacists about oral chemotherapy
28 question survey to assess pharmacists knowledge of and attitudes toward OC
Survey population Colorado, Kansas, and Southeastern United States
243 surveys returned (response rate 22.5%)
Knowledge of OC: 49.7% correct
General dosing principles: 69% correct
Special handling: 25% correct
Attitudes toward OCFew indicated comfortable dispensing these agentsMost felt knowledge of OC is very importantMajority were “very interested” in attending a program about OC
J Am Pharm Assoc 2008:48; 632-9Slide27
Of interest…
Most pharmacists did not dispense more than 5 prescriptions for oral chemotherapy weekly
Pharmacy average volume was determined to be between 350 – 1750 prescriptions per week
< 1% of all prescriptions for OC
5.3% of respondents did have a counting tray dedicated to Oral chemotherapy
J Am Pharm Assoc 2008:48;632-9Slide28
How has dispensing changed in the clinic – hospital setting
Chemotherapy preparation undergone a revolution
Specialized hoods
Specialized equipment
More protective personal equipment (PPE) recommended
Monitoring of staff and hoods for contamination
More data regarding safety available
Continued improvements Slide29
Reasons for these changes
USP 797 requirements
Improved technology
Documented increased risk of cancer in nurses (and pharmacists?) who prepared chemotherapy
Documented blood levels of chemotherapy in health care workers
With new technology, those who unpacked the drug orders from wholesaler were only staff with
levels measuredSlide30
Lets examine the newer dispensing methods in institutions
Special Thanks to Robin
Ferra
for letting us film her during the process!Slide31
How does this differ from community pharmacy?Slide32
Options for obtaining oral chemotherapy
Mail order pharmacy
Concern over quantities dispensed (90 days)
Costs
Errors: dose adjustments
Disposal of unused medications
Patient education-no interaction with the
RPh Specialty pharmaciesDrug interactions can be missedLack of accessHospital pharmacies
Clinic-based pharmaciesCommunity pharmacySlide33
Are there any published recommendations to guide practice?
American Society of Health Systems Pharmacists
National Comprehensive Cancer Network
American Pharmacists Association?
‘In the land down under’, of all places…Slide34
ASHP
No specific guidelines for community pharmacy
Extrapolating their guidelines toward community practice would include:
DOES recommend counting of
cytotoxic
drugs on a tray dedicated that class of drugs
Recommends not putting
cytotoxic drugs in automated dispensing devicesUse of personal protective equipmentPrepare agents in a designated area-do not crush, or split tabletsStates “special handling procedures policies for hazardous drugs should be established in any pharmacy setting that dispenses hazardous drugs, and all employees of the pharmacy should be educated on the policies”
Am J Health Syst Pharm 2006;63:1172-93Slide35
NCCN – national comprehensive cancer network
Task force report published in 2008 regarding oral chemotherapy
Highlights increased interest, increasing use of and concerns with oral chemotherapy
Discusses dispensing issues
Patient and health care safety
Safe dispensing: double checking, protocol driven
Costs discussed
Provides no conclusions or guidelines to improve practiceJNCCN 2008:6. Suppl 3. S1-16Slide36
What is going on in Australia?
Developed Standards of Practice for the provision of oral chemotherapy for the treatment of cancer
They are not legally binding – noted in introduction to the guide
Society of Hospital Pharmacists of Australia (SHPA) developed these
“Oral chemotherapy must be subject to the same stringent prescribing and checking procedures as chemotherapy administered by other routes”
J Pharm Pract Res 2007: 37(2) 149-52Slide37
SHPA standards
Verification of prescription
Prescription should be screened by pharmacist with experience in cancer treatment-2
nd
check
Chemotherapy must be prescribed in context of a referenced protocol
Prescription must state, for each course of therapy
DrugDoseRouteIntended start dateDuration of therapyIf relevant-intended stop dateSlide38
Dispensing elements addressed in the standards
Ensure proper dose, treatment intervals
Verify disease, laboratory values, organ function
Specific labeling instructions also delineated
Dose
Tablet number
Start/stop dates
Labeling of each boxQuantity to dispense included in the standardsCytotoxic warning stickersshpa guidelinesSlide39
Health and safety addressed
Avoid skin contact
Avoid “liberation of aerosol” of powdered medications into the air
Avoid cross-contamination of other medications
Therefore, if possible unit dose packaging is preferred
Use of gloves recommended
Hand wash after each dispensing
Separate specially designated counting tray and spatula labeled for that purposeWashed with detergent and water after useshpa guidelinesSlide40
Health and safety
No crushing or tablet splitting in pharmacy
If dose is unusual, liquids should be obtained from manufacturer, or specialized facility where compounding is done in a non-sterilized
cytotoxic
hood (not easy to locate such facilities).
Do not compound oral agents within the
cytotoxic
drug safety cabinet because of contamination—Differs from some US recommendations foundshpa guidelinesSlide41
Counseling
Required for each oral chemotherapy prescription
Can be achieved at the clinic
Written material must also be supplied
Supportive care included
24 hour access to health care team must also be included
Storage of medications – AWAY from ChildrenSafe handling of medications by family
shpa guidelinesSlide42
Example of counseling for Xeloda
Take with water within 30 minutes of a meal
If a dose is missed, do not take when you remember, and do not double-up dose next time
Stop taking and contact your oncology team if experiencing 4 or more bowel movements per day, diarrhea at night, loss of appetite, large reduction in fluid intake, if you vomit more than 1 time in a day, mouth sores, temperature greater than 100.4, or pain, redness or swelling in the hands and feet that prevents normal activity
Avoid exposure to sunlight. Wear sunscreen, lip protection, hat.Slide43
General dispensing information
Review of principles
Counseling points in general
Handout for specific agent counseling
Handling
Disposal Slide44
Information on prescription to properly verify
Patient name, date of birth, height, weight and body surface area (verified by the pharmacist)
Patient’s diagnosis
Protocol used, including other medications
Dose per m
2
and dose for the patient
Duration of therapy – specific information regarding days of therapySigned by oncologist (not the Fellow, the Resident the primary care physician, nor the secretary)Days supply should be no more than 4 – 6 weeks in general (most often less)Slide45
Obtain the protocol
In general, ask the oncology clinic to provide protocol with references,
Lexicomp
, chemoregimen.com
may contain some standard protocols
These references should be verifiedPackage insert will have minimum and maximum dosing information
Must have diagnosis to correctly verify the protocolDiagnosis should contain treatment and stage information. For example: Adjuvant breast cancer or advanced lung cancer, second line therapySlide46
Dispensing details
Obtain and use separate counting tray and spatula
Have a separate area to dispense for these agents
Clean with detergent and water-not alcohol
Use gloves
Consider having
cytotoxic
agents separate from general inventoryConsider wearing a separate laboratory coat for this activityConsider wearing a maskSlide47
Special handling
Recommended to wear gloves with
cytotoxic
agents
Also recommended with hormonal agents
Targeted therapies??Slide48
Cytotoxic agents vs
hormonal agents
cytotoxic
Temozolomide
Capecitabine
Thalidomide
Cyclophosphamide
MethotrexateProcarbazineHydroxyurea
MercaptopurineChlorambucilLomustine
hormonal
Tamoxifen
Toremefine
Exemestane
Letrozole
Anastrozole
(
Arimodex
)
Bicalutamide
Flutamide
NilutamideSlide49
Targeted therapies
Drugs
Imatinib
(
Gleevec
®)
Dasatinib (Sprycel®)Nilotinib (Tasigna®)
Lapatinib (Tykerb®)Erlotinib (Tarceva®)Gefitinib
(Iressa®)Sunitinib (
Sutent
®)
Recommendations
At this time, no special handling procedures are required.Slide50
To use the BSA to calculate a dose:
Pt height: 65”, weight: 75 kg
BSA = 1.25 m
2
using
Mosteller
Dose of temozolomide is 75 mg/m
2 dailyCalculate the dose: 75 mg/m2 x 1.25 = 93.75 mgMost likely, based on available strengths, this dose would be rounded up to 100 mg dailySlide51
Counseling principles
How/when to take medication
Address “gaps” in therapy i.e. take days 1-21 of 28 days.
Duration of treatment
What to do if miss a dose?
Swallow tablets whole, do not chew, crush
Review risks of crushing and mixing capsules with food
Review important drug-drug, drug-food, drug-herb interactionsExpected adverse effectsWhen to take supportive care medicationsPrinciples of safe handling, disposingStorageSlide52
Review days of therapy
Clinic should have provided a calendar for the patient. If not, consider developing oneSlide53
Calendar example
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
1Start capecitabine
2Capecitabine3
capecitabine
4
capecitabine
5
capecitabine
6
capecitabine
7
capecitabine
8
capecitabine
9
capecitabine
10
capecitabine
11
capecitabine
12
Capecitabine
13
capecitabine
14
LAST DAY OF
capecitabine
15
Clinic Visit
16
17
18
19
20
21
22
Start
capecitabine
23
capecitabine
24
capecitabine
25
capecitabine
26
capecitabine
27
capecitabine
28
Capecitabine
29
Capecitabine
30
Capecitabine
31
Capecitabine
1
Capecitabine
2
Capecitabine
3
Capecitabine
4
LAST DAY OF
Capecitabine
5
6
7
8
9
10
11
12
13
14
15
16
17Slide54
Counseling for specific common toxicities
Nausea and vomiting
Myelosuppression
Diarrhea
Mucositis
Hand – foot syndrome
Rash
Hypertension Serious reactions – when to contact the oncology clinic, or go to the emergency roomSlide55
Missed doses
Instruct patient not to take
whenever they “remember,”
nor double-up on medication
Contact oncology clinic if missed dosing
occurs greater than half the dosing interval
For weekly dosing (methotrexate) there is a bit of leeway here.Slide56
Nausea and Vomiting
Best managed by preventing nausea and vomiting
Nausea-hard candy, small frequent meals, chewing gum
If patient vomits more than once per 24 hours, call MD
If vomiting each day, call oncology team: reconsider oral chemotherapy
PRN scripts should be written for patients
PRN scripts:
ProchlorperazineMetoclopramideSlide57
Oral agents and N/V incidence
Cyclophosphamide
> 100 mg/m
2
Etoposide
Temozolomide > 75 mg/m2
Estramustine Lomustine (single dose)ProcarbazineLess common (< 10%):
BusulfanCapecitabine ChlorambucilCyclophosphamide < 100 HydroxyureaImatinib
LapatinibMercaptopurine Methotrexate
Sorafinib
Sunitinib
Thalidomide
NCCN.org antiemetic guidelines 2010Slide58
myelosuppression
Common dose limiting side effect:
Especially with
temozolomide
,
lomustine
, hydroxyurea, targeted therapies
Can occur with capecitabine At risk for infection – when Absolute Neutrophil count is below 500, especially when lower than 100Slide59
Counseling points for low WBC
Check for temperature – any temp
>
100.4 call the oncology team/go to ED
Any signs of infection such as: chills, cough, sore throat, shortness of breath, pain or burning on urination, pain or swelling, redness at a port site – contact the oncology team/go to ED
Avoid contact with anyone who is ill.Slide60
Anemia
Some drugs can cause anemia. Symptoms include fatigue, shortness of breath, and if history of arrhythmias, may lead to arrhythmia, chest pain. If these symptoms develop, recommend patient go to ED. Slide61
Low platelets
Symptoms would be increased bruising, and bleeding. Bloody nose, gums, urine, or stool (can also be black stools).
Any bleeding should be evaluated. If patient has bleeding, should go to ED.
Use soft toothbrush, electric razor.Slide62
Diarrhea
Commonly occurs with
capecitabine
Counseling tips
Avoid dairy, prune juice or caffeine
Replace fluids and electrolytes
If fever, go to EDLoperamide
2 tablets at start of diarrheaContinue with one tablet every 2 hours until diarrhea resolved for 12 hoursIf uncontrollable, go to EDSlide63
Mucositis
Occurs with higher doses of
methotrexate
,
cyclophosphamide
, also
capecitabinePrevention: avoid hot, spicy, foods, “sharp foods” like potato chips
Brush with soft toothbrushTreatment: avoid alcohol containing products, mouth rinsesRinse mouth out with Biotene, or sodium bicarbonate and salt rinseMagic mouthwash, Carafate suspensionSlide64
Hand-foot syndrome
Capecitabine
– most common
Also
mercaptopurine
, sorafinib
, hydroxyureaSkin reaction appears most commonly on the palms of the hands and soles of the feet
May appear on other areas body that experiences increased pressure or warmthSlide65
Incidence and causes
Some chemotherapy (
capecitabine
) risk 32 – 74%
Severe PPE 0 – 63%
Theory:
Accumulation of drug metabolites in skin, elimination of chemotherapy and metabolites through sweat glands. Vascular degeneration results in skin death in areas of high blood flow, especially with local pressure, and abrasion.Slide66
Hand-foot syndrome
Starts with several days of
dysesthesias
of the palms or soles
A painful symmetrical
erythema
appearsOften with edema
Less frequent areas involvedGroin ButtocksUnder pendulous breastsaxillaeSlide67
Hand-foot syndrome
Time to occurrence 2 – 12 days of starting therapy
With proper management, PPE can be mild and resolve in 1 – 2 weeks
If not attended to, PPE can evolve into blistering desquamation, crusting, ulceration, and epidermal necrosis
Even mild, PPE can interfere with daily activities and be uncomfortableSlide68
prevention
Reduce pressure or abrasion to the skin
Avoid blood vessel dilatation
Wear loose clothing and footwear
Keep skin moist with emollients
Avoid hot climatic conditions (warm
vs
hot showers), harsh soaps, or detergentsPat skin dry rather than rubbingEffects of prevention are modestSlide69
Treatment
Chemotherapy dose reduction
Less frequent dosing
Withdrawal from the drug
Early detection is key to preventing severe reactions
Therefore, important to counsel patient to call oncology team with any symptomsSlide70
treatment
Emollients
Bag balm, aloe
vera
lotion, urea based creams
Apply three times daily
Has demonstrated improvementsCooling measures – ice packsRecommend close surveillance during therapy – notify health care provider Slide71
Cutaneous reactions –rashes and skin eruptions
Specifically due to tyrosine
kinase
inhibitors
Usually due to agents that target EGFR
Skin, hair follicles, and nails
Within the epidermis, EGFR stimulates epidermal growth, inhibits cell differentiation, protects against sun damage, inhibits inflammation and accelerates wound healing
Resultant breaks in skin integrity and accumulation of nonviable cells favors bacterial overgrowth, and increased risk of infectionsSlide72
Why not prevent rashes?
Data suggests rash indicates better response to treatment
In some protocols, attempts made to increase dose to elicit significant skin rash.Slide73
Rash vs no rash
In one trial in pancreatic cancer, overall 81% of patients developed a grade 2 rash to
erlotinib
In patients who experienced a rash, median survival was 7.1 months (grade 1), 11.1 months (grade 2), versus a median survival of 3.3 months in patients with no rash
j Clin Oncol 2007; 25:1960-6.Slide74
General counseling for rash
Use a thick emollient cream
Protection from sunlight; use sunscreen with a minimum of SPF 15
Wear hat, coverage outside preferable
Remember the lips! Slide75
Treatment by severity
Mild: no treatment of rash, or can consider using low potency topical steroids and/or topical antibiotics such as
clindamycin
Moderate: topical hydrocortisone or
pimecrolimus
or
clindamycin
gel plus systemic antibiotics (doxycycline or minocycline)Slide76
Rash treatment by severity
Severe: systemic corticosteroid pulse and taper plus therapies for moderate rash
Mild to moderate rashes-continue cancer therapy
Severe: dose held or lowered until rash improves
Counsel patients with rash to contact oncology teamSlide77
Hypertension and heart failure
HTN Common with
sunitinib
(about 30% of patients)
Also associated with heart failure
Monitor blood pressure for first 6 weeks
Usually treated with medications Monitor for symptoms of heart failure: increased fluid, shortness of breath, fatigue (which is a common side effect)- clinic should be monitoring
ejection fraction as wellSlide78
General counseling for chemotherapy
If miss a dose, can take within dosing interval- half of the dosing
interval-
but if more than that, call oncology team
For example, daily dose, take within 12 hours, for q12 hour dose take within 6 hours
Never double up on doses!
Take at same time each day if possible
If vomit within hour of dose, call oncology teamIf vomiting – contact oncology teamSlide79
Counseling for specific agents
Refer to handout for tips on specific agents
In general, look over labeling information for changes
Important to remain updated
Remember, most of these patients are also using other agents administered at the clinic in conjunction, which will make toxicities more pronouncedSlide80
Care givers administering chemo
Wear gloves
Do not crush
Wash hands immediately following
If touching body fluids, wear glovesSlide81
Disposal of chemotherapy
Not down the toilet!
Kitty litter or coffee grounds
Sealed in regular trash-animals nor children should be able to easily open
If possible, clinic should accept back for proper storing-very few do this
Drug take-back programs
http://web.ascp.com/advocacy/briefing/upload/Reducing%20Pharm%20Waste%20White%20Paper.pdfSlide82
Conclusions – future directions
Oral chemotherapy will not replace office-based infusions of chemotherapy
Will become more prevalent
Will require more vigilance on part of the patient, the oncologist, oncology nurse, and the pharmacist
Pharmacists must become knowledgeable in safe dispensing, and proper counseling
Next step: preparing pharmacists to assist with adherence!Slide83
Survey questions…Slide84
How confident are you about your oral chemotherapy knowledge?
Not confident
Somewhat confident
Neutral
Confident
Strongly Confident
:15Slide85
Will you obtain a counting tray devoted to
oral
cytotoxic
medications?
Yes
No
:10Slide86
Will you wear gloves when handling
oral
cytotoxic
chemotherapy ?
Yes
No
:10Slide87
Will you wash hands immediately after handling
oral
cytotoxic
medications?
Yes
No
:10Slide88
Will you counsel caregivers on safe handling of
oral
cytoxic
medication?
Yes
No
:10Slide89
Will you require a double-check by another person when dispensing
oral
cytotoxic
medication?
Yes
No
:10Slide90
Which of the following oral chemotherapy agents is dosed based on Body Surface Area (BSA)?
:15
Sunitinib
Exemastane
Temazolamid
e
I don’t knowSlide91
The wife of a patient calls your pharmacy. He can no longer swallow medications unless they are liquid, or crushed. Her husband is on
Temodar
. What is your response?
Tell the wife to place in a
ziplock
bag and hit with a
mallot
, then rinse into a cup of water to drink
Prepare a liquid formulation in pharmacy by crushing tablets and mixing with simple sugar syrup, giving a 30 day expirationCall the doctor
I don’t know
:30Slide92
What counseling point(s) is/are important for a patient receiving chemotherapy that can lower white blood counts?
Call your doctor for any temperature 2 degrees above your normal temperature
If you have symptoms of sore throat, or cough, call the doctor only if accompanied by a fever
Avoid contact with anyone who is ill.
All of the above
I
don’t know
:30Slide93
Counseling for capecitabine
(
Xeloda
®) includes which of the following?
Edema is common
Take within 30 minutes of a meal
Skin rash indicates higher efficacy
All of the above
I don’t know
:20Slide94
Which of the following drugs can interact with CYP 3A4 agents?
Erlotinib
(
Tarceva
®)
Sunitinib
(
Sutent
®)Lapatinib (Tykerb®)
All of the aboveI don’t know
:15Slide95
Which of the following drugs may commonly cause hypertension?
Temodar
®
Tarceva
®
Sutent
®
All of the above
I don’t know
:10