Oral Chemotherapy – Moving Cancer Treatment into Communit - PowerPoint Presentation

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