This content is a review session for pharmacy board exams (BPS and BCOP), focusing on hematology and oncology. It aims to provide high-yield information, practical insights, and exam-relevant knowledge for pharmacists, delivered by experienced clinical oncology pharmacists.
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Okay. Well, welcome everybody. It's good
to be with you for another rapid review
session for the BPS exams. And uh this
session is going to be dedicated to he
um I will cover in the first half of the
session. Uh maybe we'll get done a
little bit early. That's my hope. um and
leave a little bit more time for the
really focused oncology section where we
have two outside experts who are
actually writers for us. They're
contributing um members of the editorial
team and write QBank questions for
specifically the BCOP exam. They are
clinical oncology pharmacists from the
University of Kentucky and practically
the Kentucky uh medical center. Um Dr.
Allison Buts and uh Dr. Dr. Elizabeth
Travers, they will be joining us in a
little while. So, uh, save your focus
questions on oncology for them because
that is not my ever expertise. Um, at
the same time, I've obviously had to
interact with, uh, chemotherapy agents
and oncology patients even in my
practice and I'm sure same for those of
you that maybe aren't oncology
specialists. the focus will be more
about you know what is on uh yes some
aspects of BCOP but what is also going
to be applicable to the nonBCOP BPS test
taker so I hope you'll find it uh
enjoyable I hope that you will um stay
on and engage with those ladies they are
fantastic and I think it'll be fun so
it's going to be a relaxing kind of fun
evening and having said that we are
going to jump into some hematology and
hemat ologic disorders and um oh sorry
that popped up a little advanced there u
but we're going to kind of talk about
anemia let me just step back for a
second anemia and when we think about
anemia there's not just one type right
you need to actually think about what is
the underlying reason in the case
uh that is guiding you to the underlying
problem so that you know how to treat it
right because we should be treating the
underlying issue and so there are sort
of classic
uh things that and I try to underline
underline line and highlight those as we
um uh go through some of these slides.
But realize that um they all present in
a very similar way for the most part. Uh
you you'll see fatigue, you know,
drowsiness or uh shortness of breath,
dismia, those are kind of just generic
that applicable to a lot of diagnoses,
but it's important to recognize that
they're going to be consistent with
anemia. So then we have to go the one
step further of trying to differentiate
really on a lot of times labs what is
the underlying problem. Um sometimes
clinical exam u can help us connect the
pathofizz which then goes to the
treatment. So I just wanted to lay that
groundwork. So when we think about
anemia of chronic disease think of a
hypo proliferative state. When you have
a chronic inflammatory condition you
know a lot of these immun modulators
they're suppressing the bone marrow.
They basically affect the way the bone
marrow utilizes components to make the
precursors and the eventually the uh
cells that would produce you know red
blood cells and and also then how the
hemoglobin looks and operates inside
that. again vague symptoms, malaise,
generalized fatigue, again with chronic
disease. When you look at their RBC
indices from a CBC with a differential,
you basically see a normic or a very
subtle microitic anemia pattern. Um you
might see some uh changes in the iron uh
iron saturation and a slight increase in
serum feritin because it's an acute
phase reactant at some level. Those are
really not super helpful. But really the
MCV, MCH, MCHC are really not that much
different. Okay? So you treat the
underlying problem, whatever that is. So
rheumatoid arthritis, you know, HIV,
CKD, you know, all these things that are
chronic medical conditions where you you
want to get to the underlying problem.
So that's pretty straightforward
thankfully easy. Now what about CKD,
chronic kidney disease? Well, the
kidneys as we know make arythropotin.
riiththopin is necessary to stimulate
that bone marrow to make red blood cells
and utilize the iron sources if they're
there to form that hemoglobin to make
the red blood cells so that you can you
know kick it out. So depending on how
bad your anemia of CKD is depending on
the degree and amount of arthropoin and
your iron stores may influence the uh
presentation. So you really need labs in
this situation. But what you see in this
particular pattern is that you see a um
a uh normal chromic uh normidic red
blood cell. Okay. Um and so when you do
the labs your your MCH, MCHC, MCV,
they're typically normal unless they're
iron deficient along with CKD, which can
happen. So that's when you get mixed.
Okay. uh but that's where really your
low arthropoin levels come into play.
Obviously you know the GFR and the
different categories of u chronic kidney
disease that would then correspond to
that. So measuring the ariththropoin
levels um helps you to see that burr
cells are a classic term to describe
some of the uh red blood cells on a
peripheral smear. They have a particular
pattern or shape um and that's a classic
description if you happen to see that in
a particular case. Now, how do we
replace um and fix this problem? Well,
if they're iron deficient, associated
also with CKD, they need iron
replacement. And and when you're talking
about CKD, many times it's parental iron
therapies because they are they already
have access points. They're already on
hemodialysis. They can just infuse the
iron in through the line and replenish
them. Because the biggest problem with
oral iron therapy, which we'll talk
about here in a couple minutes, is that
patients have a difficult time
tolerating it orally, and they have to
take it three times a day on an empty
stomach to maximize the bioavailability
of a drug that doesn't have great
elemental iron uh absorption. So, you
have to take it three times a day at
standard doses in order to replenish it.
And it may take weeks, if not months, to
achieve that. Whereas a series of 10
injections over the course of a
hemodilysis can sometimes replace that
if they have CKD. But where we're fixing
the underlying problem outside of iron
is replacing the urethropoin. As time
has gone on and you know we've learned
that too much urethropoin and and
raising the number to treat it to normal
isn't always the right thing to do for
the patient. So uh if you use
arythropoetin replacement therapies
recognize you're increasing plasma
volume which increases blood pressure
increases the risk of heart failure and
the limit should be only to start these
agents when the hemoglobin is less than
10 and you really don't want it going
really above 11. Uh outcomes worsen at
11. So that is your target point when
you're um you know managing these
patients. make darn sure. Um,
so some of you are saying you can't see
the slides.
Um, I mean the slides should be showing.
They're showing on on the screen. So,
okay. So, everybody else just telling me
that they can see them. So, u I'm going
to move on to save time here, but uh I'm
not sure exactly who that was, but all
right, macroitic anemia. So these are
red blood cells that are larger, macro,
big. Okay. Uh something's happening
where the hemoglobin isn't being really
probably produced uh correctly. And so
there's really two main underlying
common reasons for that. There's vitamin
B deficiency um in particular, some
folic acid deficiency, and then
pernicious anemia. Pernicious anemia um
is a uh basically
a chronic atrophic gastritis. Remember
your um stomach uh produces uh intrinsic
factor which is necessary in order to
um uh bind to the vitamin B12 that you
ingest and so that it can be absorbed in
the terminal illium. And so if you
either cut off the stomach or you change
the sh you know gastric bypass or if you
have an ilostomy all of those things can
reduce the absorption and develop into a
macroitic anemia. The other one that can
cause that in vitamin D vitamin B12
deficiency are patients who are true
vegans. That means they don't eat any
foods from animal sources including
cheese or milk which is very hard to do
for most people. Um and when you see
that you'll see clinical presentation
that can include paristhesas, atexia,
peripheral neuropathy because that
results in a demolination of the
posterior aspect of the spinal cord. Um,
so when you look at their RVC indices,
you see a normal reticular site count
that's less than two, but you see MCH,
MCAV, MCHC that are all elevated, so
they're plumpy, bright, round red blood
cells. And so you treat the underlying
problem. Um, if they're V B12 deficient,
you want to replace that. You need to
make sure they have intrinsic factor
present. And if you think that you can't
absorb it because you either don't have
intrinsic factor for some surgical or
autoimmune disease reason or you don't
have a terminal illium anymore because
you had maybe Crohn's disease and you
had that section removed and therefore
you can't absorb it uh then you need to
bypass the GI tract and use it
parentally. So IM injection is most
commonly considered in that situation to
adequately replace it or you have to use
very very high doses of oral vitamin B12
to maximize whatever absorption that you
can get out of them. Now microitic
anemia the red blood cell is small kind
of shriveled up a little bit. Um and
this is also due to a defect in
hemoglobin synthesis but it results in
and most commonly iron deficiency anemia
uh is the most common c subcategory of
this butthalmia
and cerlastic anemia would certainly be
other causes although they're less less common.
common.
Um so when you look at this one the RDW
which is basically in uh the red blood
cell distribution width. So it basically
looks at the sizes you'll see that the
RB RDW is very elevated. And so you have
small red blood cells big red blood
cells medium size and they're all over
the place. And then of course your iron
studies would be mimicking that where
your iron saturation is less than 20%.
Your T total iron binding capacity would
be greater than 400. And then of course
your serum iron would be less than 15.
So you see that pattern that would be
there. And again some CKD patients can
have this on top of low arythropoetin
levels. So how we replace the iron is
influenced in part by the other
indications and coorbidities. How fast
do we need this to be replaced? Okay. Um
so like I said in in CKD patients they
have the access point. So use it. um you
can bypass the GI tract because if
you're using oral replacement therapy
where you need 300 roughly milligrams of
elemental iron per day on a regular
continuous basis for several weeks in
order to replenish this that is very
difficult for most people to take. There
are drug drug interactions associated
with these drugs. There are also uh
tolerability. They get constipated. They
get nauseous. They have abdominal pains.
uh it changes the stools to very dark,
thick and tarry um looking u stools. So
it's just very difficult for anybody to
take especially like you know women who
are pregnant and they needed iron
supplements or uh even multivitamins
that are contain iron for women. I mean
it's just difficult. So parental or IV
or IM um are helpful if you use the IM
administrative method because you don't
have an IV access point and there is
nausea or issues. You just don't want
iron just kind of just extravating out
into the tissue especially the
subcutaneous tissue. It is an IM
injection and so the Ztrack method if
you end up doing that is what is recommended.
recommended.
Okay. So this all those were all related
to problems with really kind of
production right some underlying
deficiency issue you know not make
allowing the red blood cells to be
formed correctly. What about when the
red blood cell is breaking down? So you
either or you have hemolytic you're
breaking it down because you have
increased attack or destruction or
there's an increased catabolism of the
red blood cell like because it's not
sticking around uh for very long um for
some problem like cickle cell patients
don't have a normal lifespan of a red
blood cell they have greater turnover of
those red blood cells.
Um so common things that you'll see in a
case with hemolytic anemia because they
all cause weakness, tired, shortness of
breath is jaundice because when you're
licing these cells open you are
increasing the billy rubin levels um and
that obviously can then deposit. You'll
see some abnormal bruising u because the
hemolytic anemia can be rather severe.
Enlargement of the spleen is a common
characteristic. Um when you look on labs
the reticular site index is going to be
really high. your bone marrow is going
to be like, whoa, what's going on? Let's
kick out some recruits. Um, so the
reticular site index is reflective of
those new recruits that are showing up
in the blood from the bone marrow. You
have elevated, like I said, unconjugated
Billy Rubin, which is causing the
jaundice that you have because you're
having lices
up, which is an intracellular enzyme um
and marker. And then if you spear put it
on a smear and you look at them you'll
see sometimes what are called shistoytes
um and uh there are different we'll talk
about this in a minute and other forms
of uh hemolytic anemia but when you see
those you do need to be concerning that
there's shredding of the red blood cells
from something um and again I'll talk
about that with um some of the it's
basically called maha uh but we'll get
to it in a second. So if you have an
underlying cause obviously try to treat
that. There are some drugs that can be
associated with that and especially in
patients with G6PD deficiency. So that's
glucose 6 phosphate
phosphate dehydrogenase deficiency. They
lack that ability to conjugate the
processes that would uh form basically
water- soluble conjugates to facilitate
removal. And so when you have these
unstable intermediates, they're going to
react with surrounding cell membranes
and other things and steal electrons and
and they basically cause an oxidative
process that breaks down those red blood cells.
cells.
So when we encounter um this kind of uh
scenario, we need to think of also then
drugs. So what drugs would be
problematic in G6PD deficiency patients?
Well, classic ones that are slam dunk on
that are likely to be on tests are
things like Bactrumthropomoxol
is an easy one. Nitrofurenttoine
definitely another, you know, one of
those e easy ones. U some of the uh uh
uricase drugs like raspurease,
glucarase, those agents have also known
to be um associated with ticagirlore.
Um, so there are just a number of drugs
that you want to keep in mind that you
don't want to miss. Fava beans and all
that crap that people sometimes talk
about or you'll read in books. I mean, I
don't know many people that eat those u
saying that they're not common. It's
just, you know, not likely to be part of
the problem. Now, drug induced emolytic
anemia, uh, people will commonly go,
"Oh, methylopa, methodopa all day long."
Uh methylopa is not really used that
much anymore in in clinical practice for
a lot of scenarios because of some of
the side effects and problems. Um but it
certainly is still a classic one that's
out there. If you actually look at the
literature, sephosporins are reported to
be um highly contributed to cases. And
so when you see a pattern of a
consistency of a number of cases that
certainly raises that certainly with
septraxone um and then pipperylin is
another one of the betalactam
antibiotics that seems to be fairly
commonly associated with that that may
pop up again on a board exam. Uh let me
see what kind of questions some of you
Okay, so you guys are just telling us
that we can you can see the slides.
That's good. I'm glad you can see the slides.
slides.
Okay, so let's keep going with hemophilia.
hemophilia.
Uh hemophilia A and B. Um how can you
remember which clotting factor it is? I
get this mixed up and historically get
mixed up that I always try to find some
way of just identifying it. If you look
at the and I don't know if this will
help you or not, but it I'll I'll show
you my little tool. Um, but when you
look at the letter B, uh, obviously it
has like these two little bumps here,
obviously with a straight line. So if
you you got one straight line, this
represents the backbone of the B. And
then if you kind of just use an imagin,
you know, it has sort of like the B
appearance. So, uh, you know, again,
that would be factor nine and then you
have your factor 8. Uh, so I don't know
if that helps you. Uh, that's the way I
kind of remember it. So, especially when
I'm on a test and I'm like, oh, start
getting confused and I talk myself out
of something of which hemophilia is it?
But most of these patients are going to
have prolonged bleeding and many times
they present with joint eusions. Not
only is that clinically true, uh it'll
probably be involved in a case,
especially if the diagnosis isn't 100%
clear, but they should be giving you
diagnosis. But again, I'm trying to show
you patterns of association. So, you can
certainly check um labs that would show
that the clotting factors are deficient.
And so then you just do you know uh
hemophilia specific treatments where um
obviously with hemophilia B if you can
give factor 8 replacement that's helpful
or FFP uh hemophilia A is going to be if
you depends on the amount or degree of
bleeding. Um so remember some of these
FFP cryoprecipitate and these things
have you know clotting factors
precursors that are necessary for the
coagulation process to occur. So, Desmar
prein is certainly an easy one um that
can increase the concentrations of
factor 8 and then cryoprecipitate if
you're having active bleeding into a
joint and it's more severe or
concerning. All right. Von Wdebrand's
factor is one of the kind of um cohorts
if you will or cousins that carry you
know hangs out with uh some of the
clotting factors in particular factor 8.
Um so you know when it's deficient in
that it causes again problems with
bleeding and bruising. You still see the
sort of the same thing um there. Uh
that's why you want to consider the
factor 8 activity test to see how well
is it interacting with uh this um
situation and these patients have low uh
von wilderbrand or multimer test uh
results. So desmopressin
u is again uh one of the classic uh
probably treatments of choice that would
show up on a board exam that you're
likely to see factor 8 concentrates also
um you know show up antifphospholipid
syndrome. So when you think about the
pathophysiology you probably want to
think of thrombosis. So DBT pees
um and they can be in all kinds of
organs um and problems. So the the
problem with uh you have antibodies that
are basically attacking phosphoippids.
Well, phospholipids are present in a lot
of places including the endovvascular
um lining of the blood vessels. So
that's why you get both arterial or
venus thrombosis. uh for women uh who
maybe uh don't know that they have this
sometimes when you have multiple
miscarriages that is a
red flag if you will or concern that
there's a reason. So if they if a female
has had two back-toback miscarriages, it
starts to raise a little red flag that
there may be a clotting disorder and
those clotting disorders are not just
antifhospholippid syndrome but activated
protein C resistance factor 5 liden. Um
you got prothin gene mutations which
we'll talk about here in a brief in a
brief moment here. Um but you know you
just need to keep in mind that those are
classic. there's a um classification criteria
criteria
with has both both a clinical um
component and a laboratory component.
And so this laboratory u component
involves a pretty extensive uh basically
autoimmune workup. Um so when you have
connective tissue disorders um and
things like that like reayods and this
and um u scleroderma and all these other
things there's um slee uh you want to do
a workup because sometimes one auto
autoimmune disease shows up in the
context of another one. So if patients
uh obviously have this which is more
genetically uh influenced and autoimmune
mediated um then they're going to be on
lifelong anti-coagulation therapy and
the classic historical drug of choice is
warfin. Um the one little caveat here
and there's a a subtle bullet point down
below that I wanted to make sure is if
you have a patient with antifphosol
lipid syndrome and they're on war
depending on that your hospital's assay
that's being used might have difficulty
controlling their INR. Um and the reason
for that is some of the reagents that
are used in the test tube have
phospholipids in them. And so when you
take someone's blood that has
anti-phospholipid syndrome, they have
antibodies against phospholipids. So
those antibodies will bind to the
phospholipids and the reagent and create
a false
um results essentially. And so you'll
see a lot of times that especially again
if your labs don't use this right assay
that accommodates for some of this um
there's a variation all over the place.
you don't see their time in INR range as
being very good. However, we just trust
that if patients aren't bleeding and
they're not clotting that, you know, you
probably are doing okay. Um, so it's a
very relevant thing and it that's a
common test question because it creates
confusion um when people don't
understand the pathophysiology of the
problem. Moving on to some of the other
hypo hyperccoagul
disorders. Sorry, getting a little
tongue tied there. Uh anti-throen
deficiency. Um it used to be known as
anti-throen 3 deficiency. Again, this is
a autoimmune um sorry not autoimmune
autotosomal dominant disease. So it's
genetically modified where there's a
mutation of the gene that basically
doesn't produce either the same amount
or no anti-throen. um present. Now as
you know anti-throen physiologically
physiologically
is a natural or endogenous anti-coagulant.
anti-coagulant.
So it will bind to factors 10 and nine
and other factors just like like hepin
would bind to. Um hepin's use requires
anti-throin and hepin basically makes
anti-throin work more efficiently by
improving the binding affinity. So
anti-throman by itself while it's an
endogenous anti-coagulant it's not a
great one but when you're deficient in
it or don't make it then these patients
like a lot of hyperquagal disorders uh
they present with un sort of um uh uh
DBTs pees you know bte that's not
provoked by something that's clearly
obvious sometimes it just happens uh
they could be sitting for just a little
too long or maybe uh uh someone starts
estrogen based therapy for some reason
even at a very low dose that you might
see in in birth control or you know
something like that and it's just enough
to flip them over and they develop this
DBT and they've not had any surgeries
and they're otherwise young. That's why
you see typically less than age 40
listed on some of the review material.
Um, and so you just have to do labs to
when you get when you have concern for
somebody that has an a unprovoked or
unclear reason for a clot, you're doing
a hyperquagable workup. And this is one
of them. I'll talk about the other ones
here in just a second. U but you have to
use and consider then treatment that
does not fully rely on anti-throbin to
be present. So that's drugs like
unfractionated hepin. So your
traditional old school hepin drips and
subqpin. That's also your low molecular
weight hepins and also your parental
direct 10A inhibitor fondarex. Outside
of that including all the oral agents
oral DTI included, you don't need
anti-throbin uh to um to work. Um so
your direct throbin inhibitors directly
will bind to thrombin and don't need
anti-throbin to work. So it's your
balroot and leper and those agents. So
just make sure that that this is where
core knowledge of understanding the
mechanism of action actually becomes
very relevant to which drugs you pick
and you can almost check off or scratch
through answer choices on a board exam
because they're going to give you drugs
that are anti-throman dependent. Now can
you replace somebody with anti-throen
and then give them hepin and the answer
is yes. Uh there are protocols in place
that can allow you to do that. Uh I had
several patients in my training at Johns
Hopkins where we did that a lot. Um and
so you know so that's there. They'll
guide you to that as one of the answer
choices if they're really wanting that.
But most of the time people especially
in the chronic uh phase where you're outpatient
outpatient
um you're going to be using some of the
oral agents that don't rely on
anti-throbin. And so that's just the the
take-home point there.
Um factor five lighten is a problem with
factor five. That was difficult wasn't
it? Remember factor five is one of those
co-actors that's necessary in regulating
um so we have protein C and S we have
factor 5 and so remember protein C and S
can feed back and influence factor 5. So
this is also known as um uh activated
protein C resistance
um where basically the factor 5 is just
you know ignoring it. Um so if you lose
factor five or you're resistant to some
of the feedback then you will um have a
problem with uh with it. Okay. Um so
let's see. So, DVT again and PE at a
very young age, uh, younger than 40,
again, unprovoked. And so, in these
situations, again, historically, rat
poison, I mean, everybody kind of wants
to dis dismiss and give no credit to
Warframe, but it's still a viable option
for people. Is it the ideal option?
Certainly not. Uh, but it is a viable
option that you can certainly consider
because when you look at at some of the
other doaxs, they're not perfect either.
I mean they have renal dosing issues,
drug interaction issues. And while we do
have antidotes and reversal agents for
all of these drugs, including warfin,
they obviously don't require all the
extensive titrations of doses and labs
and all that kind of stuff, but they're
not benign either, but clearly are
helpful. Uh factor uh or prothroin
mutation. Um prothin is thromben. And so
this G22NA
mutation is the actual location of the
uh nucleotide polymorphism that
essentially uh creates too much um
factor or two. So you put them into a
hyperquagal state. The more thrombin you
have available, the more likely you can
form a thrombus um and activate fibbrin
into its forms that create you know the
clot. So again, unprovoked early DBTs.
Um you would do again a hyperquagal
workup and you would find the gene
mutation and sort of the same drug. So
the the good news is for these agents,
they're all a lot of times treated the
same. You just got to know which one it
is um that's causing the problem.
Protein CNS deficiency. So these are the
regulators of the clotting cascade. So
when they're present, they're slowing it
down. So if you're deficient, you allow
the coagulation cascade to to continue
to expite. That's how you have to think
about it. So think of them as almost
like anti-coagulants,
if you will, but they're when they're
deficient, so they're not providing a
stopping of the anti coagulation
cascade. They allow it to continue to uh
propagate. So again, unprovoked. Um you
would look for the protein uh C
deficiencies um and even the mutations.
And again your treatments. Now this is
where warfin is a h maybe not. Um and so
why? Well because you guys remember
vitamin K dependent clotting factors
which all have varying different half-
livives. Uh protein CNS have one of the
shortest halfife. So when you initiate
somebody on warfin, you initially put
them in a hyperccoagulable
state and that's where you can get these
kind of glucose syndromes and sort of
microvascular clots that form and that's
true and that's why people will bridge
patients on uh anti-coagulation
um in these patients to avoid that if
they're going to use warfin. That's not
necessarily true for the other agents.
It's really true for the um uh drugs
like warfin. Golly, that's two. Sorry
about that, guys. Uh cickle cell
disease. There's a problem and a
mutation in the hemoglobin um strand. So
how it folds. So remember proteins have
a primary, secondary, tertiary, and a coronary
coronary
orientation. And so this causes a
deformed shaped red blood cell that is
more likely to break down. It also
doesn't um it can clog up vessels and so
that's why when you see the presentation
here it's long because depending on the
target organ that is uh being affected
um it can be from a stroke they could be
having acute kidney disease they have
avascular necrosis of the hip they can
have a priaprism which is a prolonged
erection u they can like I said they can
have a myocardo infarction acute chest
syndrome I mean it's all over the place
okay so anywhere these cells uh collect
and um clog up a vessel can certainly do
that. So in these situations analesia is
key. Um they suffer from a lot of
eskeeia and pain and quite honestly uh
you're not your answer is not in NSAIDs
in this situation. Um it's actually
appropriate doses of opioids and do they
become physically dependent on them?
Absolutely. Um is that just part of the
problem? Yes, it is. But the reality is
there's disease isn't going away. So, el
glutamine um
the uh that's you know come to the
market. Uh we now have an oral another
agent that helps to reduce some of the
polymerization of the hemoglobin
molecules that are also uh can be used.
All right. So now there's two other
forms of uh kind of going a little bit
back to some platelet problems and maybe
even a little bit of hemolytic anemia.
we have ITP and TTP U and when we think
about thrombocytoenia
uh what is happening to these platelets
well this is immune mediated so it's
basically antibodies that form against
the platelets um and this can cause
obviously bleeding so they usually
classically in a case you'll see fatiki
which are these little spots
um in different places on the skin they
look like little broken blood vessels
and then um um nose bleeds that are
pretty significant GI bleeds. Um they
can have also had spontaneous intra
cerebral hemorrhage if the platelets are significantly
significantly
uh low especially less than 10,000. So
you can see platelets less than 50,000
is the most common. um because it's
autoimmune we need to suppress the
immune system and the classic drugs and
sometimes even in combination with each
other are those uh splinctomies are
obviously an invasive procedure I mean
you have to keep that in mind especially
depending on how many platelets they
have whether or not they can you know
clot um but IVIG methyl predinisolone
predinisolone predinazone are going to
be your key um treatments treatments
there. When you have thrombotic
thrombocyopedic parapura, so that's TTP.
This is where maja shows up. Maha being microangopathic
microangopathic
hemolytic anemia. So they have breakdown
of red blood cells, but this is due to
an absence or a decreased level of atoms T13.
T13.
Um and basically what happens is uh you
form these thrombi and then the red
blood cells are trying to push their way
through that and when they do that it
causes a hemolysis or breakdown of the
red blood cells and
um they uh on on a smear have those
shistytes or they can present with
shistytes uh present. So they have the
maja um classic presentation. They're
forming platelet aggregations. They have
development of thrombocytoenia with
target organ damage. And in this one
again I think they'll probably pick on
plasma exchange or plasma feresis plus FFP
FFP
um in combination with methyl
prediniscolone in particular uh as the
primary treatment. So I tried to
underline and hit those uh for you. Um
all right hepin induced thrombocytoenia.
This is where hepin is binding with
platelet factor 4 on the surface of a
platelet. And when they do when it does
that it creates an antigenic stimulus
point that basically causes the body to
form antibodies against that
uh complex. And when the antibbody binds
to the platelet it turns on the
platelet. It doesn't destroy the
platelet, it turns it on and activates
it. And so what ends up happening in
heperinduced thrombocyopenia is these
patients are forming basically thrombus
and they're clogging up forming emblei
everywhere and that's why their
platelets are dropping. That's why
they're thrombocytoenic.
Um and it's because the platelet factor
4 release causes basically an activation
um and stimulation of the platelet
causes activation of the local
endogenous areas of the coagulation
cascade. So they start forming thrombus
in different places. So what are you,
you know, going to do? Um, sorry. One of
the tools that you can use to in a
workup or if they put it on a case is a
4T score. Um, again, you don't need to
memorize scores and risk stratification
tools. You just kind of want to be
familiar with the what the tool is. Um,
you can look it up, but it's not going
to show up on a board exam from you
having to calculate it. Um but again
this is usually occurring in the context
of heperin or low molecule hepin use and
hepin unfractionate hepin tends to occur
cause it more so more so than patients
with um
uh low molecular weight hepins because
of the size of the molecule seems to
influence the risk of binding to
platelet factor 4. So unfractionary
upper causes it more, low molecular eper
causes it less and then fontarinex
causes it the least and so much so that
foperex is sometimes used to treat hit
even though it's not FDA approved for
that. So you want to stop the
anti-coagulant whether it's low
molecular heperin or unfractionate
heperin that must be happening first and
foremost remove the stimulant. Second is
you need to now start them back on
another anti-coagulant even with
thrombocytoenia. Um, and the reason for
that is remember the platelets are re
going down because you're forming clots
everywhere and so the platelets are
being consumed or used and it sort of
seems counterintuitive to give them an
antiquagulant, but you're going to
continue the anti-coagulant until their
platelets uh function resolve and they
maintain uh two levels of platelet
counts above 100,000 and because as soon
as you stop the anti-coagulant uh their
platelets are potentially going to drop
again. Um so it's important to keep keep
these subtle treatments um in mind. Just
keep in mind the other one that people
like to use is denapoid. The drug of
choice in these input is a direct thumb
inhibitor like leperodin balrudin those
kind of drugs. Um denapoid is not
available in the United States. All
right. Um platelet dysfunction. So in
this particular situation
uh patients um have platelets that are
present in normal numbers but they're
dysfunctional. That means they have a
functional problem that is preventing
them from aggregating. And so what does
the uremia part of the name come from?
That's basically in patients with CKD.
So they accumulate these metabolites and
some of these byproducts of metabolisms
and things that we would normally
eliminate in our urine that will be
removed in hemodiolysis.
But if they're not um compliant with
hemodilysis or uh they're not adequately
clearing some of these things, then you
can have platelets that are basically
dysfunctional and so they can just
spontaneously start bruising and
bleeding everywhere. Um and and GI
bleeds and such things like that. So you
have to be very careful with this.
Historically um the way these patients
were identified is they had prolonged
bleeding times. Literally you would cut
the patient and watch them bleed and
wait for the bleeding to stop and you
you have a stopwatch and essentially um
take discern how long does it take them
to stop bleeding. Um now PTT aptTTS can
be prolonged in these um but it you know
so that but it's not the sensitivity uh
of those lab tests are not always 100%.
So how do we how do we uh prevent this?
Well one reason one thing to treat is by
prevention. So that is your ESA or those
are your ariththro uh poet and
stimulating agents or EPO uh analoges
that you're basically replacing in CKD.
Uh again, you don't want to raise that
uh hemoglobin above 11 because you
worsen the outcomes through increased
viscosity, blood plasma uh pressure, uh
plasma volume, all this kind of stuff.
But you want to build it up enough so
that this has to do with how the uh
blood vess uh platelets and things flow
through a laminar tube. Um and so when
you have lower amounts of anemia, it
pushes those platelets to the surface of
the endovvascular lining so that they
can actually be activated when they need
to be. Then proper use of hemodialysis
to remove these waste products of
metabolism appropriately.
If you find yourself in an active
bleeding scenario, then this is the
situation where you want to use
cryoprecipitate and desmopressin.
uh desmopressin will probably be the
answer choice. You've seen desmopressin
show up a couple times. So make sure you
keep that in the proper context.
Hemophilia in particular hemophilia a um
you see it here. So it's just one of
those that sometimes we get a little
confused about um but those two um
things will facilitate. So the there one
other drug that potentially
could show up is estrogen. Um, and I
know that sounds weird, but remember,
think about what estrogen does. Estrogen
increases the production of clotting
factors. And if you increase the number
of clotting factors, that provides more
clotting factors to come together and
kind of rub shoulders where they can um,
basically cause, you know, clots to
form. So, all right. So, that's our
that's the heem section. Um, we're going
to uh stop here in a minute. I'm gonna
put the give you guys a break and um get
Dr. Butts and Dr. Travers on with us and
um we'll get get them set up and uh
we'll come back and we'll start
oncology. But I wanted to ask real quick
if make sure uh there weren't any quick
questions that I could maybe address
even though we do have a uh Q&A session
um after the oncology. All right. So the
there was a question about is it okay to
still use Lovvenox as a bridge when
initiating Warfin when somebody with
anti-throman deficiency and the answer
is absolutely
uh you can you can do it. It's just more
difficult and exposes the patient to um
you know more drug and risk of bleeding.
Um but it's not contraindicated to do
that. Um,
oh I see it was sorry deficiency sorry
blah step let me step back if you have
some presence of anti-throen
then the answer is yes if you have
absent anti-throen or it's un like
basically undetectable then it's not
going to do anything a heperin doesn't
work without the presence of of um
anti-throman it requires it all which
would drugs uh with not FDA approved
indications like pond paranex for hit
beyond the exam. Miranda, that's a great
question and most likely it would not uh
because there's debate uh about that in
people's different level of comfort. Um
and so but you'll see it commonly
discussed even in physician statements
and review articles. So it's not that's
the division of clinical relevance
versus a board exam. So probably not.
However, if the all the other answers
were flatout wrong, then maybe they are
wanting you to recognize that even
though it's an off label use because we
use offlabel treatment all the time. So,
the treatments Connie of HIT include
stop the hepin molecule whether it's
unfraction hepin or low or low molecular
hepin that's first and foremost stop it
and then you start them on a direct thin
inhibitor as firstline therapy. So like
balrud and leperodin those you know
those drugs. Um
other people will list denaperoid in
list and that's true but it's not
available in the United States at least
to my knowledge. And then this the last
one would be something like fond of
paranex. Uh again off label um and
even though the product package insert
actually mentions that you um uh it can
cause basically hit. So, you know, but
it's very low risk. It has to do with
the size. Uh Amanda is asking a question
about which IV iron formulation has the
most chance of uh reactions and
anaphilaxis. And that is the old school
um uh iron dextran uh the um when you
look at some of the iron sucrose, iron
fummerates, and the other agents,
they're less likely to do it. And so
that doesn't mean that you can't use
regular generic iron dextrin that you
just most people would consider giving a
test dose to consider that. There are
some clinicians who have had bad
experiences and so they only want to use
the other formulations um like iron
sucose and those um agents. So um but
that's the answer to the question. Uh
can you repeat the treatment uh for
hemophilia A and B? So um hemophilia A
is predominantly uh desmopressin um uh B
is FFP and uh the uh or I think it's I
think that's right and then factor eight
or I'm sorry factor 9 replacement. Um so
it depends on what your uh um lab has.
Okay guys, we're going to go on a uh
break. So stretch your legs. Uh, get
your DVT prophylaxis, move around, um,
get your get your cup of coffee. Um, and
get your notes out, uh, because we're
going to hit some oncology here in, uh,
just a few minutes. So, see you guys
back. We will start
uh, around 7:30. So, we're going to take
a maybe a good 10 to 12, 13 minute uh,
break. Um, so stretch your legs. See you
So guys, we are on a quick uh break uh
in between the sessions. We're going to
be starting the oncology section here in
a minute. So we'll see you guys back
here in just a few minutes. So by 7:30
we'll be back on. We just finished the
heem section. So we'll be back to you
>> Okay. Can you hear me now? >> Yes.
>> Yes.
>> Okay. I don't know why it said I was muted.
>> Okay.
Are we good? Can you hear me at this
time, too? I hear myself. So, >> yes,
>> the background on the little poll is
Okay, so we are we are on break, guys.
Um, and so I let them uh stretch their
legs and so we'll get started here in a
minute. Um, so I'm just going to get
everything kind of back up
and on the screen. So we just finished
uh the hematology
uh section. So we'll move on to oncology
here in just a minute. So, um, I also
told them, you know, get out notes and,
you know, so I have my notes here, too.
And, uh, we'll just get started here in
a minute. So, there were a few questions
I think I'll look at
that came in.
>> Right. Should I turn my brightness down
on the lamp?
>> Nope, you're good.
>> Okay. I just feel like I'm like glowing
compared to Alison.
>> Let me see. the worm light on like the
blue one.
>> Yeah. No, you're you're you guys are
fine actually.
>> Okay. I'm also significantly paler. So,
I got that going for me. I called my
sister before this. I was like, "Do I
look like a ghost?" And she was like,
"No, you look better than the other
day." And I was like, "All right, we'll
>> Oh, goodness. Um, so you guys might be
able to see too on the on like the
panel. uh the questions as they start
coming in. You'll see a little question
mark pop up. Um and that'll just kind of
give you a guidance. Um we're going to
try to not um gravitate to doing those
um in the midst unless we unless the um
time is going okay. So, I'm going to be
monitoring us just to try to keep us on
track. But there are a couple questions
from the previous um section. Let me
just see.
So you'll see like people will put
comments in there. They'll kind of chat
with you
>> via um
uh the questions essentially, but
they'll just talk to you. Um they can't
see each other's
>> comments, so I will kind of read them
out loud. Um so you don't have to worry
about managing that. That's that's on
Well, we I'll accept uh any questions
you guys have at this time. Um I know
we're going to we still have a few more
minutes. uh we got on a little quicker
and we always take a little extra um
time to ensure that we uh account for
technological glitches because techn
technology is either our friend or um
our enemy and it seems like when you
when you want it to work it doesn't and
uh when it you know it just it's just
bizarre how it unfolds. So,
um if anybody while you're if you're
coming back from the break and you have
any questions uh regarding hematology
um then we can certainly do that. Uh as
a reminder also for those of you that
are on and listening um on
the next session for the live study
group Q&As's I think it's March 28th. uh
we will uh be uh on uh live all three of
us. So um and that'll be specific for
oncology related uh discussions and
questions. We'll certainly answer or I
will answer if there's other topics that
um Dr. Travers and Dr. Buts don't feel
um uh comfortable maybe addressing
because of their areas of expertise in
oncology. Um, but it's really going to
be focused on oncology.
So, um, you know, bring your questions.
We will send out and it's on, if I'm not
mistaken, the web page, um,
um,
that you can submit questions ahead of
time. And we would respectfully ask that
you try to do that. And because what it
will do, especially if there's a lot of
people that submit questions or you, you
know, a lot of people start writing in
questions all of a sudden, you know,
then we're going to go through them as
they come in in the order that they're
received. Um, and I'd hate for somebody
to be sitting around, you know, too long
waiting for just a simple question that,
you know, one of us can answer for you.
So, if you can, we'll send out a email
for anybody that's registered for these
sessions um in advance. So, register if
you're going to invite friends or
colleagues, remember this, those are
open to the public. So, anybody studying
any material, you don't have to be a
customer of High Yield. You can invite
friends, colleagues, whatever. Um and um
but if you can submit those questions
ahead of time so so that maybe if there
are some similar questions we can
consolidate them or coate them in groups
and maybe address them as holes
especially if there's a lot of questions
um because we're only dedicating really
an hour uh to um that that session. Um,
so we'll have a little Q&A session after
we finish oncology here in a minute. Um,
but um,
we really want to try to keep it f
focused on maybe some of the things that
are related to what we're discussing and
try not to get on too many rabbit trails
because we want to respect everybody's
time, especially for those of you on the
east coast where you're, you know, even
later into the um, e day. So, okay. So,
let's see if there's any.
All right. Hi, Connie. So, how intense
is a BCPS in oncology?
Uh, or is it standard eyes core
knowledge? So, it's a great question,
Connie, and I am going to make a comment
about that here.
Well, I guess I could start. I guess I
could do that. We're kind of on time
now. Um so
to answer your question Connie uh so the
BCPS exam is obviously a exam that's
broad from pediatrics to geriatrics
everything in between and ages acute
care to chronic care everything around
it. Um so you and then there is
obviously certain areas and some people
um do practice in subsp specialcialized
area that are BCPS certified and they're
experts in that area but quite honestly
I've never heard or seen I took the exam
myself um though it was many years ago
um it is more of the management
recognizing the things that we're going
to talk about tonight. So this is really
for the nonBCOP
person. That doesn't mean that for those
of you that are on that are preparing
for BCOP,
this is still going to be applicable to
your exam. It's just probably not the
level of difficulty and depth that some
of the content you would be expected to
know for the board exams um for BCOP
would have. So that's a separate thing.
So we want to be careful not to go too
deep um into you know um the minutiae of
the oncology world because it's it's
constantly changing. So for BCPS think
of of supportive care um issues uh dose
limiting toxicities monitoring
parameters many of the things that we're
going to cover tonight. So if you pay
attention to things tonight and in your
rapid review books that you have access
to that will um be what you need. Okay.
So, um we're going to go ahead and get
started here. And I'm really excited
because we have two of our contributing
um writers and u to the uh editorial
team who have written um oncology
related questions for the BCOP exam um
with us. And I'm going to let each one
of them just introduce themselves very
quickly. Um, and you know, just tell us,
you know, what your uh, you know, your
name, your area of practice, where where
you practice now, and um, and we'll get started.
started.
>> I can go first alphabetically, I guess.
>> Yeah, there you go.
>> Great. All right. I'm Allison Buts. I'm
a board certified oncology pharmacist,
as you can see. I've been at the
University of Kentucky for about seven
and a half years now. I believe my area
of expertise is breast oncology. Um, but
where I work, I have some exposure to
most solid tumors, not so much
hematology anymore, but I'm happy to be
with you all today.
>> So, hematology is where I come in. Um,
I'm Elizabeth Drivers. I'm also a board
certified oncology pharmacist at the
University of Kentucky. I have been at
UK going on three years now. Um, and my
area of expertise is hematology and bone
marrow transplant. So leukemia,
lymphoma, multiple myoma, bone marrow
transplant, cartis cell, um kind of
anything in that realm. So Allison and I
have pretty much opposite kind of
specialties here. So hopefully we can
give you guys some good information
across all of oncology.
>> Absolutely. So guys, as we dive into
this, uh first of all, we all going to
relax. You can see I've got my coffee.
I've got my my notes. Um oncology is a
rather frightening and intimidating
environment um and specialty because the
drugs are complicated. They have a lot
of issues with them and I can't even
pronounce half of them anymore. So I am
I feel very safe and I'm super uh happy
to have Allison and Beth with me here um
to lean on. uh at the same time that
doesn't mean that I haven't interacted
with uh patients with um various cancers
and on chemotherapy. I practice in
emergency medicine and I do see uh the
complications of chemotherapeutic agents
that are used the old traditional agents
and some of even the newer agents. Um so they do show up. I mean, and so you need
they do show up. I mean, and so you need to be able to recognize some of those
to be able to recognize some of those classic toxicities.
classic toxicities. Um, so that you kind of get to the
Um, so that you kind of get to the underlying problem and you don't waste a
underlying problem and you don't waste a bunch of time doing a a massive workup
bunch of time doing a a massive workup on something that is really just a
on something that is really just a complication that is expected at some
complication that is expected at some level. Um, at the same time, you also
level. Um, at the same time, you also want to be able to know how to
want to be able to know how to appropriately treat them. And and so
appropriately treat them. And and so we're going to be hitting sort of the
we're going to be hitting sort of the high points and we're going to start off
high points and we're going to start off by covering dose limiting toxicities of
by covering dose limiting toxicities of the traditional agents which have been
the traditional agents which have been around for decades. And that kind of
around for decades. And that kind of information is for the most part pretty
information is for the most part pretty well established. If you basically if
well established. If you basically if you have to memorize it, you just have
you have to memorize it, you just have to memorize it. We'll try to make it
to memorize it. We'll try to make it um easy to understand, you know, try to
um easy to understand, you know, try to give you little pearls or try to connect
give you little pearls or try to connect dots where you don't have to memorize
dots where you don't have to memorize everything. But I think you'll find that
everything. But I think you'll find that that if you know these things, they're
that if you know these things, they're probably going to be good for that. Uh
probably going to be good for that. Uh we will talk about monoconal antibodies.
we will talk about monoconal antibodies. Uh we'll do a little brief generic
Uh we'll do a little brief generic overview uh because they're unique
overview uh because they're unique dosage formulation and have a very
dosage formulation and have a very specific targets and then also tyrroscen
specific targets and then also tyrroscen kinace inhibitors. So those are the two
kinace inhibitors. So those are the two other sort of groups that have evolved
other sort of groups that have evolved over um you know the years and are now
over um you know the years and are now integrated and there the number of drugs
integrated and there the number of drugs coming out just keeps growing and
coming out just keeps growing and growing and I can't keep up with them
growing and I can't keep up with them and so that's where Allison and Beth
and so that's where Allison and Beth come in. Um and then we will move into
come in. Um and then we will move into some of this other supportive care
some of this other supportive care issues. Um we'll cover um chemotherapy
issues. Um we'll cover um chemotherapy induced nausea, vomiting, chemotherapy
induced nausea, vomiting, chemotherapy related or induced uh diarrhea. Um we'll
related or induced uh diarrhea. Um we'll also step you know step into a little
also step you know step into a little bit of fe fibbral neutropenia and then
bit of fe fibbral neutropenia and then um uh um tumorlyis syndrome. Um so you
um uh um tumorlyis syndrome. Um so you know these are again common classic uh
know these are again common classic uh things and so again very relaxed we're
things and so again very relaxed we're just going to talk about some of these
just going to talk about some of these things and Allison and Beth are going to
things and Allison and Beth are going to chime in. So, what we've tried to do and
chime in. So, what we've tried to do and and for those of you that do have your
and for those of you that do have your uh rapid review book, you know that you
uh rapid review book, you know that you have a little bit more detail in there.
have a little bit more detail in there. So, try not to frantically write down
So, try not to frantically write down notes because you have this in your
notes because you have this in your study book. Um, and those of you that
study book. Um, and those of you that are studying the BCOP exam have, you
are studying the BCOP exam have, you know, the other topics that are written
know, the other topics that are written in the book format for you. So you feel
in the book format for you. So you feel free to obviously reflect back because
free to obviously reflect back because this information is somewhat coming out
this information is somewhat coming out of that. What we want to do is kind of
of that. What we want to do is kind of talk about the key points.
talk about the key points. So alkalating agents bleomyosin buculpan
So alkalating agents bleomyosin buculpan those have I mean those are the ones I
those have I mean those are the ones I remember been around for a long time
remember been around for a long time cycloposphomide
cycloposphomide you know iphosphamide
you know iphosphamide you know I what we've tried to do is you
you know I what we've tried to do is you know underline again probably and again
know underline again probably and again Allison and Beth you know I'm gonna let
Allison and Beth you know I'm gonna let you jump in here and add any points that
you jump in here and add any points that you feel like are necessary but you know
you feel like are necessary but you know we're trying to help you to identify the
we're trying to help you to identify the ones that are most likely going to be
ones that are most likely going to be the identifiers
the identifiers um anything that you guys have to add
um anything that you guys have to add here or comments that you want to make
here or comments that you want to make about it?
about it? >> Yeah, I can definitely talk about
>> Yeah, I can definitely talk about malfin. It's a staple in our bone marrow
malfin. It's a staple in our bone marrow transplant regimens. Um that's the main
transplant regimens. Um that's the main place you kind of see it nowadays. Um
place you kind of see it nowadays. Um but it you could occasionally have an
but it you could occasionally have an outpatient on maybe an oral malfin
outpatient on maybe an oral malfin tablet. Um the biggest thing with malfin
tablet. Um the biggest thing with malfin aside from your general chemo side
aside from your general chemo side effects, you know, nausea, vomiting,
effects, you know, nausea, vomiting, hair loss, is the mucusitis. And that's
hair loss, is the mucusitis. And that's all the way from your mouth through your
all the way from your mouth through your entire GI tract. So these patients can
entire GI tract. So these patients can get terrible mouth sores and terrible
get terrible mouth sores and terrible diarrhea. So those are like my two
diarrhea. So those are like my two biggest counseling points when I talk to
biggest counseling points when I talk to these patients. Had one of them today
these patients. Had one of them today actually. Um so to help prevent the
actually. Um so to help prevent the mucusitis with malfin patients actually
mucusitis with malfin patients actually can chew on ice and it vasoc constricts
can chew on ice and it vasoc constricts your oral mucosa and kind of prevents
your oral mucosa and kind of prevents some of that chemotherapy damage. It
some of that chemotherapy damage. It works because it has such a short
works because it has such a short halflife. Doesn't really apply to a lot
halflife. Doesn't really apply to a lot of our other drugs unfortunately. Um but
of our other drugs unfortunately. Um but if someone gets moplin, expect them to
if someone gets moplin, expect them to have oral mucusitis and diarrhea from GI
have oral mucusitis and diarrhea from GI mucusitis.
mucusitis. >> So what about hemorrh what about
>> So what about hemorrh what about hemorrhagic cyitis? What do we I mean is
hemorrhagic cyitis? What do we I mean is this legit and what do we do with it?
this legit and what do we do with it? >> I was just going to jump into that one
>> I was just going to jump into that one next. So
next. So >> oh there you go.
>> oh there you go. >> So I think a couple things to keep in
>> So I think a couple things to keep in mind. We've got cycloposphomide and
mind. We've got cycloposphomide and iphosamide both listed here. Um I think
iphosamide both listed here. Um I think generally speaking IOS is the one that
generally speaking IOS is the one that we see hemorrhagic cyitis for more
we see hemorrhagic cyitis for more commonly and part of the reason I would
commonly and part of the reason I would say that is because we generally only
say that is because we generally only worry about it with highdosese
worry about it with highdosese cyclophosamide more like what we use in
cyclophosamide more like what we use in bone marrow transplant. In a solid tumor
bone marrow transplant. In a solid tumor world we use cycloposomide all the time
world we use cycloposomide all the time but less than half the doses that vets
but less than half the doses that vets patients get. Um so in my population
patients get. Um so in my population hemorrhagic cyitis not really an issue
hemorrhagic cyitis not really an issue for cycloposomide bets it is. So keep in
for cycloposomide bets it is. So keep in mind that dose release uh dose
mind that dose release uh dose relationship there. Whereas IOS
relationship there. Whereas IOS absolutely hemorrhagic cyitis. So
absolutely hemorrhagic cyitis. So there's a drug called mezna that's given
there's a drug called mezna that's given with phosphomide and highdose
with phosphomide and highdose cyclophosamide as a protectant of the
cyclophosamide as a protectant of the bladder. It's a really cool drug um
bladder. It's a really cool drug um which we won't go into for the sake of
which we won't go into for the sake of time here but um protective of the
time here but um protective of the bladder to try and prevent this bleeding
bladder to try and prevent this bleeding that can happen due to damage of the
that can happen due to damage of the cells itself. So key one to keep in mind
cells itself. So key one to keep in mind there. All right guys, that was
there. All right guys, that was excellent. So mucositis, pulmonary
excellent. So mucositis, pulmonary fibrosis, hemorrhagic cyitis and oh
fibrosis, hemorrhagic cyitis and oh accidentally jumped ahead. All right,
accidentally jumped ahead. All right, let's move into the imomodular
let's move into the imomodular modulatory agents. Um this is your
modulatory agents. Um this is your theolyomide and lolyomide and I mean
theolyomide and lolyomide and I mean theomide obviously has historical
theomide obviously has historical you know negative things associated with
you know negative things associated with it um with the teratogenicity and the
it um with the teratogenicity and the dismillia that you know basically
dismillia that you know basically extremities and stuff and we've all seen
extremities and stuff and we've all seen some of those pictures that were you
some of those pictures that were you know devastating
know devastating um and so this is why these drugs are in
um and so this is why these drugs are in the REM uh you know kind of program so
the REM uh you know kind of program so really to ensure that providers are
really to ensure that providers are using them appropriately and for the
using them appropriately and for the right indications. anything here guys
right indications. anything here guys that we need to uh further
that we need to uh further >> yeah definitely um these drugs are used
>> yeah definitely um these drugs are used pretty much exclusively for multiple
pretty much exclusively for multiple myyoma um lenolyomide pomolyomide and
myyoma um lenolyomide pomolyomide and felomide the rem program is absolutely
felomide the rem program is absolutely in place for the risk of birth effects
in place for the risk of birth effects it's also in place because of risk of
it's also in place because of risk of VTE it's pretty significant with these
VTE it's pretty significant with these agents and they have blackbox warnings
agents and they have blackbox warnings for VTE stroke and MI so any patient who
for VTE stroke and MI so any patient who is on one of these three drugs has to be
is on one of these three drugs has to be on some sort of anti-coagulant. At the
on some sort of anti-coagulant. At the very least, everyone needs to be on a
very least, everyone needs to be on a baby aspirin. If your patient has other
baby aspirin. If your patient has other risk factors for a blood clot, you
risk factors for a blood clot, you probably want to consider full dose
probably want to consider full dose anti-coagulation. So, that's my mental
anti-coagulation. So, that's my mental checklist. If someone's on an IMID, I
checklist. If someone's on an IMID, I have to make sure that they're on at
have to make sure that they're on at least a baby aspirin.
least a baby aspirin. >> Excellent. I mean, do you think that
>> Excellent. I mean, do you think that BCPS I mean, that seems that seems fair
BCPS I mean, that seems that seems fair to me. Uh is that is that too difficult?
to me. Uh is that is that too difficult? I mean,
I mean, >> I think that's a fair question. I will
>> I think that's a fair question. I will admit, full disclaimer, I never took
admit, full disclaimer, I never took BCPS. I went straight to VCOP. Um, but
BCPS. I went straight to VCOP. Um, but when I think about folinomide,
when I think about folinomide, bondolinomide, pomly, that's like my one
bondolinomide, pomly, that's like my one thing that I'm like, okay, baby aspirin.
thing that I'm like, okay, baby aspirin. So, if I had to pick the most important
So, if I had to pick the most important thing about the drug, that's what I
thing about the drug, that's what I would say it is.
would say it is. >> Yeah, I agree. Um, all right, perfect.
>> Yeah, I agree. Um, all right, perfect. Those were excellent points. Um, let's
Those were excellent points. Um, let's move on to the anthrocycles. I think
move on to the anthrocycles. I think this one is also a classic
this one is also a classic uh because of the cardiomyopathy and the
uh because of the cardiomyopathy and the toxicity that seems to be uh dose
toxicity that seems to be uh dose related. Uh what what do we need to know
related. Uh what what do we need to know about this?
about this? >> Yeah. So definitely the key there is the
>> Yeah. So definitely the key there is the dose relationship again with the cardiac
dose relationship again with the cardiac toxicity. So there's obviously a risk
toxicity. So there's obviously a risk with any dose but there's a very clear J
with any dose but there's a very clear J curve that you could see with where the
curve that you could see with where the risk of cardiotoxicity increases. The
risk of cardiotoxicity increases. The other thing to be aware of there, we've
other thing to be aware of there, we've got the cumulative dose there of doc
got the cumulative dose there of doc rubeson specifically, but there's
rubeson specifically, but there's actually conversions and that's beyond
actually conversions and that's beyond the scope of BCPS, but there are
the scope of BCPS, but there are conversions to get equal um dosing
conversions to get equal um dosing equivalents of each of these in terms of
equivalents of each of these in terms of the cardiac risk. So, kind of like with
the cardiac risk. So, kind of like with opioids how you've got that equal anesic
opioids how you've got that equal anesic dosing table, you can convert different
dosing table, you can convert different doses of different anthrocycling to get
doses of different anthrocycling to get to your cumulative dose risk so that
to your cumulative dose risk so that you're making sure that patients stay
you're making sure that patients stay well below that threshold. um to reduce
well below that threshold. um to reduce the risk. There's cardiorop protectants
the risk. There's cardiorop protectants available as well um dexoxane
available as well um dexoxane specifically that can be used to try and
specifically that can be used to try and limit the risk at higher doses higher
limit the risk at higher doses higher cumulative doses of anthroycans but
cumulative doses of anthroycans but definitely a key to keep in mind with
definitely a key to keep in mind with this class of drug
this class of drug >> and that is also the treatment for
>> and that is also the treatment for extravisation too isn't it?
extravisation too isn't it? >> Yes. So there is two different brand
>> Yes. So there is two different brand names of dexoxane. Okay. Ptetech and um
names of dexoxane. Okay. Ptetech and um why am I blanking on the other one?
why am I blanking on the other one? >> Zenocard.
>> Zenocard. >> Zen card. Thank you. I'm like has card
>> Zen card. Thank you. I'm like has card in it. So two different brands,
in it. So two different brands, different dosing, different
different dosing, different administration. But yes, the same
administration. But yes, the same protectant for two different indications
protectant for two different indications and extraation being the other key. So
and extraation being the other key. So these drugs are given through a central
these drugs are given through a central line to try and eliminate extravisation.
line to try and eliminate extravisation. >> Right. And most people most patients uh
>> Right. And most people most patients uh have ports, right? I mean because I know
have ports, right? I mean because I know when they come in, you know, to the
when they come in, you know, to the emergency department, they get they've
emergency department, they get they've been stuck a million times and you don't
been stuck a million times and you don't want to you not not only do you not want
want to you not not only do you not want those drugs to extra extraversate into
those drugs to extra extraversate into the tissue uh but you you also don't
the tissue uh but you you also don't want to keep poking these patients. I
want to keep poking these patients. I mean they've their vessels get worn out
mean they've their vessels get worn out uh by that. So um I'm thankful for the
uh by that. So um I'm thankful for the ports and I'm sure you guys are too for
ports and I'm sure you guys are too for the administration of these medic
the administration of these medic >> medications. Anything else on that one
>> medications. Anything else on that one or we'll move on to folate antagonists
or we'll move on to folate antagonists like the old school methtoresate but
like the old school methtoresate but used in much different doses than
used in much different doses than rheumatoid?
rheumatoid? >> Yes, I think we can move on to
>> Yes, I think we can move on to methodate. Another one of my I guess
methodate. Another one of my I guess favorite drugs, drugs I use often. Um,
favorite drugs, drugs I use often. Um, when we're talking about oncology uses,
when we're talking about oncology uses, we're talking about significantly higher
we're talking about significantly higher doses. Um, like you just kind of
doses. Um, like you just kind of mentioned a lot of your rheumatoid is
mentioned a lot of your rheumatoid is like small doses once a week orally. I'm
like small doses once a week orally. I'm talking I give patients sometimes eight
talking I give patients sometimes eight grams per meter squared at once IV. So
grams per meter squared at once IV. So huge huge difference between you know 20
huge huge difference between you know 20 milligrams orally once a week and what I
milligrams orally once a week and what I kind of give patients. Um when we're
kind of give patients. Um when we're talking about those really high doses
talking about those really high doses you can see really bad mucusitis
you can see really bad mucusitis um and you can also see bone marrow
um and you can also see bone marrow suppression and cytoenas which is really
suppression and cytoenas which is really your kind of rate limiting toxicity with
your kind of rate limiting toxicity with those agents can be hard on the liver
those agents can be hard on the liver hard on the kidneys. most important
hard on the kidneys. most important thing is drug interactions with highdose
thing is drug interactions with highdose methtoresate. Penicillins, NSAIDs can
methtoresate. Penicillins, NSAIDs can all decrease your clearance of methtoate
all decrease your clearance of methtoate and cause increased toxicity. Um so if
and cause increased toxicity. Um so if your patient goes to the ICU or comes
your patient goes to the ICU or comes into the emergency department, we don't
into the emergency department, we don't want to give them zosin. We need to give
want to give them zosin. We need to give them sephop or something else if they
them sephop or something else if they have a fever. Um also glide methtrixate
have a fever. Um also glide methtrixate patients need a folate rescue. Methtoate
patients need a folate rescue. Methtoate works by inhibiting dihydroofolate
works by inhibiting dihydroofolate reductase. So it prevents formation of
reductase. So it prevents formation of folate and folic acid in your body. So
folate and folic acid in your body. So we need to give a rescue to protect your
we need to give a rescue to protect your healthy cells from that chemo. So that's
healthy cells from that chemo. So that's a medication called lucavorin. Um and
a medication called lucavorin. Um and it's given after chemo highdosese
it's given after chemo highdosese methtoate specifically to try to help
methtoate specifically to try to help prevent some of those side effects from
prevent some of those side effects from occurring to your healthy cells. And
occurring to your healthy cells. And isn't there a another antidote like if
isn't there a another antidote like if you really had true concerns like that
you really had true concerns like that you're going to kill the bone marrow or
you're going to kill the bone marrow or wipe it out is that isn't it
wipe it out is that isn't it glucarpidase or something like that?
glucarpidase or something like that? >> Glucarpidase is an enzyme as evidenced
>> Glucarpidase is an enzyme as evidenced by the ending of the drug name with ACE
by the ending of the drug name with ACE and that will actually break down the
and that will actually break down the methate in the body instead of waiting
methate in the body instead of waiting for it to kind of naturally be cleared.
for it to kind of naturally be cleared. Um, it like many drugs is horrifically
Um, it like many drugs is horrifically expensive. So, we save it for kind of
expensive. So, we save it for kind of life-threatening cases of a methate
life-threatening cases of a methate overdose. Um, if the patient isn't
overdose. Um, if the patient isn't clearing it, if their kidneys kind of
clearing it, if their kidneys kind of crap out on us, whatever it might be.
crap out on us, whatever it might be. Um, not something we use. We try to
Um, not something we use. We try to avoid using it. I think I've maybe used
avoid using it. I think I've maybe used it once in my career so far. So, we're
it once in my career so far. So, we're doing okay, but it is an option if your
doing okay, but it is an option if your patients need it. At one point back in
patients need it. At one point back in the day when I remember when it first
the day when I remember when it first came out, you um couldn't even get it
came out, you um couldn't even get it like or you couldn't stock it. You had
like or you couldn't stock it. You had to like call.
to like call. >> It gets dropped.
>> It gets dropped. >> Yeah. It gets drop shipped overnight.
>> Yeah. It gets drop shipped overnight. You call and they like basically chop it
You call and they like basically chop it in.
in. >> Wow. That's That's a legit drunk when
>> Wow. That's That's a legit drunk when you get you get escort to the hospital.
you get you get escort to the hospital. That's legit, right?
That's legit, right? >> Yeah.
>> Yeah. >> Um Wow. Yeah. So I mean we obviously for
>> Um Wow. Yeah. So I mean we obviously for you know non oncology related conditions
you know non oncology related conditions when you know as Dr. Travers was talking
when you know as Dr. Travers was talking about mentioning you know rheumatoid
about mentioning you know rheumatoid arthritis you know we use in low doses
arthritis you know we use in low doses and you can still get subtle effects on
and you can still get subtle effects on this especially if it's used chronically
this especially if it's used chronically but clearly at the doses used in
but clearly at the doses used in oncology the risk is significantly
oncology the risk is significantly higher. All right moving on to our
higher. All right moving on to our favorite most emagenic drug on the
favorite most emagenic drug on the planet.
planet. cyplatten is like associated with all
cyplatten is like associated with all kinds of toxicity and I even struggled
kinds of toxicity and I even struggled with like should I even put even CNS
with like should I even put even CNS toxicity on here because it kind of pops
toxicity on here because it kind of pops up a lot but you knowity
up a lot but you knowity nephrotoxicity
nephrotoxicity I mean you just have to know this like
I mean you just have to know this like it is slam dunk um anything that what
it is slam dunk um anything that what can we do to prevent nephrotoxicity
can we do to prevent nephrotoxicity uh do you guys do this in clinical
uh do you guys do this in clinical practice to maybe that might show up on
practice to maybe that might show up on a board exam I would think for BCPS Yes.
a board exam I would think for BCPS Yes. >> Yeah. So, when patients have cy platin
>> Yeah. So, when patients have cy platin on their regimen, it's going to be a
on their regimen, it's going to be a full day visit pretty much. They get two
full day visit pretty much. They get two hours of hydration prior to the infusion
hours of hydration prior to the infusion of chemotherapy and then two hours of
of chemotherapy and then two hours of hydration afterwards generally with some
hydration afterwards generally with some potassium and magnesium in as well
potassium and magnesium in as well because it tends to cause loss of those
because it tends to cause loss of those electrolytes. So, it is a very long
electrolytes. So, it is a very long experience. Um, it definitely helps to
experience. Um, it definitely helps to protect the kidneys with the fluids, but
protect the kidneys with the fluids, but it's a long process.
it's a long process. >> Is that just pushing it through? Is that
>> Is that just pushing it through? Is that I mean is that basically what you're
I mean is that basically what you're trying to do is keep it dilute and
trying to do is keep it dilute and prevent the contact time and just
prevent the contact time and just keeping them diaring. Is that what the
keeping them diaring. Is that what the >> in a nutshell? Yeah. To try and protect
>> in a nutshell? Yeah. To try and protect as much as you can by just flushing
as much as you can by just flushing everything out.
everything out. >> All right.
>> All right. >> Um so caroplatin has a lesser risk of
>> Um so caroplatin has a lesser risk of nephrotoxicity. Um the other key drug in
nephrotoxicity. Um the other key drug in this class very important to note with
this class very important to note with caroplatin a couple things is currently
caroplatin a couple things is currently it's dosed based on renal function
it's dosed based on renal function actually. So if a patient has
actually. So if a patient has significant renal dysfunction, cy platin
significant renal dysfunction, cy platin is not a good idea because of the risk.
is not a good idea because of the risk. Caroplatin you can use because you're
Caroplatin you can use because you're basically dose adjusting it individually
basically dose adjusting it individually for each dose that's given based on that
for each dose that's given based on that day's creatinine clearance. So a very
day's creatinine clearance. So a very interesting drug in that regard. Um it's
interesting drug in that regard. Um it's also listed on here that it's mostly
also listed on here that it's mostly most likely to cause thrombocytoenia. So
most likely to cause thrombocytoenia. So kind of fun fact on that one. It used to
kind of fun fact on that one. It used to be dosed based on platelet count. So
be dosed based on platelet count. So they would watch how far the platelets
they would watch how far the platelets drop from one cycle to the other and
drop from one cycle to the other and kind of titrate the dose to response of
kind of titrate the dose to response of the platelets. Whereas now it's dose
the platelets. Whereas now it's dose based on renal function. So kind of an
based on renal function. So kind of an interesting class of drugs.
interesting class of drugs. >> Now does is it amostine
>> Now does is it amostine is that a I heard like I think that's a
is that a I heard like I think that's a option. I don't know. Do do y'all use
option. I don't know. Do do y'all use that anymore?
that anymore? >> No. Manitol and Ammaine have both fallen
>> No. Manitol and Ammaine have both fallen out of favor significantly. So really
out of favor significantly. So really it's just your hydration is the key.
it's just your hydration is the key. >> Good old IV fluids.
>> Good old IV fluids. >> Yes. And then push hydration after the
>> Yes. And then push hydration after the patient has left as well. So it's not
patient has left as well. So it's not just the four hours. It's
just the four hours. It's >> Yeah. I mean it's just like uh
>> Yeah. I mean it's just like uh hypercalcemia malignancy, right? You get
hypercalcemia malignancy, right? You get that, you know, calcium of 13. It's
that, you know, calcium of 13. It's fluids,
fluids, >> right?
>> right? >> You know, keep it simple.
>> You know, keep it simple. >> Yeah. People want to do that.
>> Yeah. People want to do that. >> Always the answer in oncology. Fluids
>> Always the answer in oncology. Fluids will never be wrong.
will never be wrong. >> All right. So 5FU uh I mean what else
>> All right. So 5FU uh I mean what else can you say outside of diarrhea? I mean
can you say outside of diarrhea? I mean that that that tan and by the way guys
that that that tan and by the way guys we'll we're going to come back to the
we'll we're going to come back to the aogenicity of these and diarrhea towards
aogenicity of these and diarrhea towards the end of the of the lecture. But uh
the end of the of the lecture. But uh anything else with 5FU
anything else with 5FU >> go ahead.
>> go ahead. >> Another key is hand and foot syndrome.
>> Another key is hand and foot syndrome. >> Okay.
>> Okay. >> So fivefu and the oral version of 5FU
>> So fivefu and the oral version of 5FU called capytoine.
called capytoine. >> Hand and foot syndrome is a big deal. So
>> Hand and foot syndrome is a big deal. So what is that? It's basically sunburn of
what is that? It's basically sunburn of the hands and feet, the palms and the
the hands and feet, the palms and the soles. Redness, blistering, tenderness,
soles. Redness, blistering, tenderness, huge issue causes a lot of dose
huge issue causes a lot of dose adjustments to be needed for this class.
adjustments to be needed for this class. So yeah, diarrhea and hand and foot
So yeah, diarrhea and hand and foot would be the two big ones.
would be the two big ones. >> Gosh, it just, you know, when you hear
>> Gosh, it just, you know, when you hear some of these toxicities,
some of these toxicities, I mean, you can empathize with patients
I mean, you can empathize with patients like just why everybody's nervous and
like just why everybody's nervous and scared about going on these drugs. I
scared about going on these drugs. I mean, it's just you hear some of these
mean, it's just you hear some of these horror stories and it's, you know, I
horror stories and it's, you know, I don't know. This being hearing you guys
don't know. This being hearing you guys talk about it, you know, is again
talk about it, you know, is again reminder to me of like I don't know if I
reminder to me of like I don't know if I want this if that ever happens to me.
want this if that ever happens to me. >> Just until you tell them about secondary
>> Just until you tell them about secondary malignancies when you're counseling
malignancies when you're counseling them. It's like,
them. It's like, >> oh yeah.
>> oh yeah. >> Yeah.
>> Yeah. >> The chemo we're giving you can cause
>> The chemo we're giving you can cause cancer and then we actually use the same
cancer and then we actually use the same drug that gave you the cancer to treat
drug that gave you the cancer to treat the cancer that it just gave you. So,
the cancer that it just gave you. So, >> that was always fun to explain. Yeah,
>> that was always fun to explain. Yeah, that's not that's not encouraging. I'm
that's not that's not encouraging. I'm going like, why would I want to do that?
going like, why would I want to do that? You know, it's kind of like the
You know, it's kind of like the conversation that I have, you know,
conversation that I have, you know, about using thrombolytic therapy and,
about using thrombolytic therapy and, you know, es schemic strokes. You know,
you know, es schemic strokes. You know, >> it's this drug that's going to break
>> it's this drug that's going to break down the clot that's causing your
down the clot that's causing your problem, but by the way, I could
problem, but by the way, I could hemorrhagically convert you into another
hemorrhagically convert you into another stroke.
stroke. >> So, it's like, uh, I don't know that I
>> So, it's like, uh, I don't know that I want to do that, you know, but it's very
want to do that, you know, but it's very those are tough decisions. Okay, the
those are tough decisions. Okay, the taxes. I remember the hands and the
taxes. I remember the hands and the feet. Okay. Uh because the peripheral
feet. Okay. Uh because the peripheral neuropathy, that's the way I remember
neuropathy, that's the way I remember it. You know the you know the hands and
it. You know the you know the hands and the feet. Um
the feet. Um what and my understanding is this some
what and my understanding is this some of this has to do with the mechanism
of this has to do with the mechanism microtubules. So it seems like drugs
microtubules. So it seems like drugs that affect microtubial formation seem
that affect microtubial formation seem to be as commonly associated with
to be as commonly associated with peripheral neuropathy. So that's all the
peripheral neuropathy. So that's all the also the vinka alkaloids if I'm not
also the vinka alkaloids if I'm not mistaken. Uh but I but I'm going to shut
mistaken. Uh but I but I'm going to shut up because I'm not an expert.
up because I'm not an expert. >> So this is another uh kind of dose
>> So this is another uh kind of dose related toxicity, cumulative dose
related toxicity, cumulative dose related toxicity with the peripheral
related toxicity with the peripheral neuropathy. So it's not something that
neuropathy. So it's not something that generally shows up immediately. It's
generally shows up immediately. It's something that we can kind of monitor
something that we can kind of monitor for over the course of therapy and make
for over the course of therapy and make adjustments along the way if needed. Um
adjustments along the way if needed. Um generally reversible but not always if
generally reversible but not always if we push it too far. Um so I'd keep in
we push it too far. Um so I'd keep in mind the peripheral neuropathy. The
mind the peripheral neuropathy. The other major one here is hypersensitivity
other major one here is hypersensitivity reactions and those are largely based on
reactions and those are largely based on the solvents that are used to formulate
the solvents that are used to formulate these drugs into solution. Um but very
these drugs into solution. Um but very serious reactions. We actually had a
serious reactions. We actually had a patient code on Friday for her first
patient code on Friday for her first pletel infusion and ended up in the ED.
pletel infusion and ended up in the ED. Um so we premedicate with two
Um so we premedicate with two antihistamines and steroids to try and
antihistamines and steroids to try and limit those reactions from happening but
limit those reactions from happening but they still happen generally with a first
they still happen generally with a first or second infusion. Very serious for
or second infusion. Very serious for those. So when they come in with the an
those. So when they come in with the an hyper sensitivity reaction because I
hyper sensitivity reaction because I don't know that I've seen that uh I I've
don't know that I've seen that uh I I've not had a patient come in with
not had a patient come in with anaphilaxis or hyper sensitivity or
anaphilaxis or hyper sensitivity or cardiac arrest at any from these drugs.
cardiac arrest at any from these drugs. What do you is there any treatment
What do you is there any treatment difference other than initiating
difference other than initiating obviously you know life-saving measures
obviously you know life-saving measures ACLS all that kind of stuff.
ACLS all that kind of stuff. >> Yeah. So you make a good point. The
>> Yeah. So you make a good point. The reason you don't see it a lot is because
reason you don't see it a lot is because it's generally happening while the
it's generally happening while the patient is actively hooked up to
patient is actively hooked up to treatment and anaphilaxis and severe
treatment and anaphilaxis and severe reactions like that are very uncommon.
reactions like that are very uncommon. Generally it's more of low-grade
Generally it's more of low-grade flushing a little tacicardia perhaps but
flushing a little tacicardia perhaps but generally very mild um depending on the
generally very mild um depending on the severity we'll give rescue medications
severity we'll give rescue medications like benadryil higher dose steroids
like benadryil higher dose steroids epinephrine in that case but generally
epinephrine in that case but generally they're much more mild than that thanks
they're much more mild than that thanks in part to the premedication efforts
in part to the premedication efforts that we make but do know it's an
that we make but do know it's an immediate infusion reaction more so than
immediate infusion reaction more so than anything delayed
anything delayed >> okay well y'all just keep
>> okay well y'all just keep >> the most
>> the most >> Go ahead go ahead
>> Go ahead go ahead >> I was gonna say most important thing if
>> I was gonna say most important thing if any patient's ever reacting to anything
any patient's ever reacting to anything is turn it off. Sometimes then all the
is turn it off. Sometimes then all the kind of hoopla concern especially it
kind of hoopla concern especially it doesn't happen in the infusion center
doesn't happen in the infusion center often sometimes people don't think to go
often sometimes people don't think to go over to the pump and turn it off. So
over to the pump and turn it off. So like that could be a question on the
like that could be a question on the oncology boards on BCPS I'm not as sure
oncology boards on BCPS I'm not as sure but like what's the first thing you do
but like what's the first thing you do and it'll be like give epie start CPR
and it'll be like give epie start CPR the answer is always turn the medication
the answer is always turn the medication off
off >> that I mean gosh it seems so
>> that I mean gosh it seems so straightforward we laugh a little bit
straightforward we laugh a little bit about it but it is like when your
about it but it is like when your anxiety goes up like common sense
anxiety goes up like common sense sometimes just goes out the window
sometimes just goes out the window >> because you're you know you're having
>> because you're you know you're having anaphilaxis while the patient's having
anaphilaxis while the patient's having anaphilaxis and it's like deep breath
anaphilaxis and it's like deep breath and you know take it off and I will even
and you know take it off and I will even like when I've had this happen with non-
like when I've had this happen with non- chemotherapy related situations in the
chemotherapy related situations in the department you know like betalactams
department you know like betalactams that you you know you just didn't know
that you you know you just didn't know or whatever you know I actually have the
or whatever you know I actually have the nurse un decap you know take it off and
nurse un decap you know take it off and cap the IV and even withdraw out
cap the IV and even withdraw out anything that you can potentially just
anything that you can potentially just to reduce even some further exposure
to reduce even some further exposure that's how much just get it away from
that's how much just get it away from the patient so somebody doesn't
the patient so somebody doesn't accidentally turn it back on
accidentally turn it back on >> uh or something so it's a Great point.
>> uh or something so it's a Great point. Common sense. Uh, okay. Ironic tea can.
Common sense. Uh, okay. Ironic tea can. I ran to the can. That's all I remember.
I ran to the can. That's all I remember. >> That's it. That's all you need to know.
>> That's it. That's all you need to know. >> No, it's true though, right? I mean, we
>> No, it's true though, right? I mean, we probably don't want we Let's talk about
probably don't want we Let's talk about it for, you know, because this is one of
it for, you know, because this is one of those chemotherapy induced, you know,
those chemotherapy induced, you know, things of diarrhea that is pretty
things of diarrhea that is pretty significant.
significant. >> Yes.
>> Yes. >> Yeah.
>> Yeah. >> And it's very different. All of our
>> And it's very different. All of our order sets actually include atropene as
order sets actually include atropene as your kind of quoteunquote antidote for
your kind of quoteunquote antidote for the immediate diarrhea. So not something
the immediate diarrhea. So not something that you would generally think of as a
that you would generally think of as a treatment for diarrhea, but it's
treatment for diarrhea, but it's immediately available for anybody
immediately available for anybody getting around a teacan.
getting around a teacan. >> All right. So remember I ran to the can,
>> All right. So remember I ran to the can, right? Genetics. Tell me, you know, back
right? Genetics. Tell me, you know, back you know, we we incorporate
you know, we we incorporate phiccogenetics into this and one of the
phiccogenetics into this and one of the pharmaccogenetics tests that we talked
pharmaccogenetics tests that we talked about um in the previous sessions was
about um in the previous sessions was the UGT1A1
the UGT1A1 genetic polymorphism with Arona TCAN. Do
genetic polymorphism with Arona TCAN. Do you guys test for that? Is it re, you
you guys test for that? Is it re, you know, I mean, is that is there point of
know, I mean, is that is there point of care testing? What what is the issue
care testing? What what is the issue with that? And how do you know if
with that? And how do you know if someone has it?
someone has it? >> Um, I guess I'll speak to that. Beth,
>> Um, I guess I'll speak to that. Beth, you don't really use this drug very
you don't really use this drug very often.
often. >> I don't use anymore. So,
>> I don't use anymore. So, >> yes. So, TKEAN as well as many others
>> yes. So, TKEAN as well as many others like 5FU have different polymorphisms
like 5FU have different polymorphisms that can affect how the drugs are
that can affect how the drugs are metabolized and subsequent toxicity. So
metabolized and subsequent toxicity. So our institution we do not routinely
our institution we do not routinely check for any of those mutations in our
check for any of those mutations in our patient population. Pediatrics is a
patient population. Pediatrics is a little bit more um forward thinking I
little bit more um forward thinking I would say about some of that and do
would say about some of that and do routinely test for more of these. But
routinely test for more of these. But no, we generally don't. It's more so if
no, we generally don't. It's more so if they have a lot more severe toxicity
they have a lot more severe toxicity than you would expect,
than you would expect, >> that's when we would check it to see.
>> that's when we would check it to see. >> You suspect it at that point you just
>> You suspect it at that point you just turn it off or you stop using it. for
turn it off or you stop using it. for the most part at this point a lot of
the most part at this point a lot of these genetic tests in our practice is a
these genetic tests in our practice is a little bit more academic than something
little bit more academic than something that you're going to put into play
that you're going to put into play because generally you would just change
because generally you would just change therapies but otherwise you could
therapies but otherwise you could certainly dose reduce the medication if
certainly dose reduce the medication if they do have a known mutation.
they do have a known mutation. >> Okay. So the so the take-home point from
>> Okay. So the so the take-home point from the when we because phiccogenetics is
the when we because phiccogenetics is obviously listed on blueprints for a lot
obviously listed on blueprints for a lot of the BPS exams and you know when you
of the BPS exams and you know when you think about the drugs that are going to
think about the drugs that are going to potentially make it they have to be
potentially make it they have to be somewhat established known entities and
somewhat established known entities and issues.
issues. >> Yeah
>> Yeah >> either guidelines say that you should
>> either guidelines say that you should check it like with a back of an HIV
check it like with a back of an HIV patient or a tcan. But basically I guess
patient or a tcan. But basically I guess guys if aranotic is you know being used
guys if aranotic is you know being used and someone starts to develop you know
and someone starts to develop you know toxicity then especially that's unclear
toxicity then especially that's unclear then you probably should be thinking
then you probably should be thinking that is the underlying potential
that is the underlying potential contributor to it because I think it's
contributor to it because I think it's the neutropenia that people get too get
the neutropenia that people get too get ultimately worried about. Um
ultimately worried about. Um >> right.
>> right. >> Right. Yeah. And with the five a few
>> Right. Yeah. And with the five a few agents, there's something called DPD
agents, there's something called DPD deficiency that again you run into
deficiency that again you run into severe cytoopenas and mucasitis. Um far
severe cytoopenas and mucasitis. Um far greater than what you would ever expect
greater than what you would ever expect somebody to get with those drugs. So I
somebody to get with those drugs. So I think maybe in three five years we'll be
think maybe in three five years we'll be having a very different conversation
having a very different conversation about these polymorphisms. Right now we
about these polymorphisms. Right now we definitely know they're a thing. Um but
definitely know they're a thing. Um but I wouldn't suspect it to be fair game on
I wouldn't suspect it to be fair game on a BCPS exam. I don't think we really
a BCPS exam. I don't think we really were tested on it in BCOP.
were tested on it in BCOP. >> Okay. All right.
>> Okay. All right. Vinka alkaloids a little bit like the
Vinka alkaloids a little bit like the taxes peripheral neuropathy right uh I I
taxes peripheral neuropathy right uh I I think of the V's as the forearms to the
think of the V's as the forearms to the you know the hands the tea um that's
you know the hands the tea um that's getting little way I try to remember
getting little way I try to remember created little ways to you know help
created little ways to you know help myself through the exams when the some
myself through the exams when the some of these drugs um what else anything
of these drugs um what else anything else we need to know with this one
else we need to know with this one >> yeah so your vinka alkaloids cause
>> yeah so your vinka alkaloids cause peripheral neuropathy that can be really
peripheral neuropathy that can be really severe um so we always address patients
severe um so we always address patients uh assess test them, see how it's going,
uh assess test them, see how it's going, and dose reduce their venal alkaloids if
and dose reduce their venal alkaloids if they're having neuropathy. Not only does
they're having neuropathy. Not only does it cause neuropathy, tingling in the
it cause neuropathy, tingling in the fingers and toes, but also causes
fingers and toes, but also causes neuropathy of the gut. So, these
neuropathy of the gut. So, these medications cause constipation as well.
medications cause constipation as well. So, if you can kind of think of that
So, if you can kind of think of that neuropathy in both fingers and hands and
neuropathy in both fingers and hands and the gut, you'll have the two biggest
the gut, you'll have the two biggest side effects of these medications kind
side effects of these medications kind of memorized with that one little linker
of memorized with that one little linker there. Um, it's also extremely important
there. Um, it's also extremely important to remember to never ever ever ever ever
to remember to never ever ever ever ever ever ever
ever ever give these intratheally. Never ever ever
give these intratheally. Never ever ever in case you missed it the first 10 times
in case you missed it the first 10 times I said it. Um,
I said it. Um, it is always fatal. Um, then Christine
it is always fatal. Um, then Christine is given in a lot of acute lymphoplastic
is given in a lot of acute lymphoplastic leukemia regimens that also include
leukemia regimens that also include intratheal chemotherapy and it's a IV
intratheal chemotherapy and it's a IV push. So they used to prepare it in
push. So they used to prepare it in syringes. it would accidentally be given
syringes. it would accidentally be given intratheally and it was always fatal. So
intratheally and it was always fatal. So now it's recommended to only be
now it's recommended to only be compounded in like a 50 ml mini bag. So
compounded in like a 50 ml mini bag. So even though it's an IV push, we do it as
even though it's an IV push, we do it as a quick like 10-minute infusion to help
a quick like 10-minute infusion to help kind of prevent those errors from
kind of prevent those errors from happening and prevent future deaths. So
happening and prevent future deaths. So never ever ever allow it to be given
never ever ever allow it to be given intratheally.
intratheally. >> Excellent. I mean even those stressful
>> Excellent. I mean even those stressful those stressing points there that you
those stressing points there that you make you know help us to remember that
make you know help us to remember that you know especially with stories you
you know especially with stories you know it's it's the simple things that we
know it's it's the simple things that we can do to for patient safety like the IV
can do to for patient safety like the IV bag is a way to help minimize that
bag is a way to help minimize that because who's going to pick up an IV bag
because who's going to pick up an IV bag and try to squirt it you know or
and try to squirt it you know or administer it through a different route
administer it through a different route other than IV. Okay guys to keep us
other than IV. Okay guys to keep us moving along we're going to finish up
moving along we're going to finish up the last two kind of drug classes if you
the last two kind of drug classes if you will the monoconal antibodies. Uh so I
will the monoconal antibodies. Uh so I will just give a brief kind of highlevel
will just give a brief kind of highlevel uh overview of it and then we'll kind of
uh overview of it and then we'll kind of allow Allison and Beth to kind of you
allow Allison and Beth to kind of you know chime in um on these. So monoconal
know chime in um on these. So monoconal antibodies um what's you know unique
antibodies um what's you know unique about them is they're very specific
about them is they're very specific targets uh drug dosage formulations but
targets uh drug dosage formulations but they're also based on their dosage
they're also based on their dosage formulations being monocone antibodies
formulations being monocone antibodies they're are large proteins and because
they're are large proteins and because of that being their large proteins they
of that being their large proteins they can degrade and be denatured in acidic
can degrade and be denatured in acidic environment. So these are not things
environment. So these are not things that you know you can administer by
that you know you can administer by mouth. So we always think of monocon
mouth. So we always think of monocon antibodies even for other conditions
antibodies even for other conditions like ulcerative colitis and Crohn's
like ulcerative colitis and Crohn's disease you know rheumatoid arthritis
disease you know rheumatoid arthritis drugs like you know adalumab and
drugs like you know adalumab and infleximab and those agents are all ms
infleximab and those agents are all ms as well uh they're all being given
as well uh they're all being given subcutaneously or introvenously for that
subcutaneously or introvenously for that reason. So that's just a classic sort of
reason. So that's just a classic sort of dosage formulation thing. Their name is
dosage formulation thing. Their name is also established to create some um
also established to create some um consistency and a systematic approach.
consistency and a systematic approach. So the IN World Health Organization
So the IN World Health Organization basically if you break down the ending
basically if you break down the ending of the name and you go backwards it
of the name and you go backwards it starts to help you to understand the
starts to help you to understand the target and then also the type of
target and then also the type of antibbody that is because not all anti
antibbody that is because not all anti not all antibodies are the same and so
not all antibodies are the same and so when you look at the MAB that's
when you look at the MAB that's obviously the consistent piece monoconal
obviously the consistent piece monoconal antibbody but the letter or two letters
antibbody but the letter or two letters before that which represent the sub stem
before that which represent the sub stem B tell you or give you the indication of
B tell you or give you the indication of what was the antibbody formed from. What
what was the antibbody formed from. What kind of other protein sources are they?
kind of other protein sources are they? Because if they're not human, then when
Because if they're not human, then when you bring in foreign protein substances,
you bring in foreign protein substances, there's always a risk that your body
there's always a risk that your body will view that protein as foreign, not
will view that protein as foreign, not supposed to be there. It's going to
supposed to be there. It's going to react against it. And so you can see and
react against it. And so you can see and this is available you know um in the
this is available you know um in the lectures there that you have or the
lectures there that you have or the notes that try to kind of help you to
notes that try to kind of help you to wrap your mind around the formula uh the
wrap your mind around the formula uh the the the um antibbody and where it came
the the um antibbody and where it came from so you can kind of predict that
from so you can kind of predict that risk. Then the sub stem A which is even
risk. Then the sub stem A which is even going further again to the left in the
going further again to the left in the uh letters is to the where is it
uh letters is to the where is it targeting like organ systems. So
targeting like organ systems. So cardiovascular fungal we have neurobone
cardiovascular fungal we have neurobone um I mean if you think of of a drug like
um I mean if you think of of a drug like for osteoporosis denosumab
for osteoporosis denosumab right so denosumab is uh targeting
right so denosumab is uh targeting obviously the osteoplastic activity of
obviously the osteoplastic activity of the bone and can you know modulate that
the bone and can you know modulate that activity in the context of osteoporosis.
activity in the context of osteoporosis. So it's guiding you in a systematic way.
So it's guiding you in a systematic way. So the very first part of the name is
So the very first part of the name is really up to the manufacturer. Um but
really up to the manufacturer. Um but after that point there is a part of the
after that point there is a part of the name that is already codified in a using
name that is already codified in a using a a naming convention process that is
a a naming convention process that is established. Um and you can see that the
established. Um and you can see that the targets are many um and you know do I
targets are many um and you know do I think you need to memorize all these for
think you need to memorize all these for a non BCOP exam? Um I don't think so. Um
a non BCOP exam? Um I don't think so. Um I think there are some targets that
I think there are some targets that create more problems
create more problems for patients that we will see. So when
for patients that we will see. So when we were talking about dose limiting
we were talking about dose limiting toxicities of some of those traditional
toxicities of some of those traditional anti-neoplastic agents or
anti-neoplastic agents or chemotherapeutic drugs, well
chemotherapeutic drugs, well these drugs have similar issues and they
these drugs have similar issues and they seem to be consistent by their target,
seem to be consistent by their target, right? U and those are the ones that are
right? U and those are the ones that are probably the more problematic that show
probably the more problematic that show up a lot at least seems like on reviews
up a lot at least seems like on reviews and boards and stuff like that are the
and boards and stuff like that are the uh last three here uh specifically uh
uh last three here uh specifically uh VEGF and the epidermal growth factor
VEGF and the epidermal growth factor receptors. So when we think about
receptors. So when we think about epidermal growth factor receptor like
epidermal growth factor receptor like epidermis where is that? Well those are
epidermis where is that? Well those are cell lines that are predominantly of
cell lines that are predominantly of your skin, GI tract and your lungs. So
your skin, GI tract and your lungs. So what do you think then is if we target
what do you think then is if we target that and we block the activity of that
that and we block the activity of that me uh um receptor then what what do we
me uh um receptor then what what do we what type of you know reactions or dose
what type of you know reactions or dose limiting toxicities potentially are we
limiting toxicities potentially are we going to see? Well, they're going to be
going to see? Well, they're going to be in those areas those organ systems
in those areas those organ systems because that's where the cell lines are.
because that's where the cell lines are. So it kind of helps you put two and two
So it kind of helps you put two and two together. So if you kind of memorize or
together. So if you kind of memorize or know some of the basic drugs or the drug
know some of the basic drugs or the drug class and what they target, then it kind
class and what they target, then it kind of coincides then hopefully in a little
of coincides then hopefully in a little bit more of an intuitive way what the uh
bit more of an intuitive way what the uh side effects are. Same thing with the
side effects are. Same thing with the vascular endothel growth factor
vascular endothel growth factor receptors that are being antagonized.
receptors that are being antagonized. These are going to help form blood
These are going to help form blood vessels, right? So if you think about a
vessels, right? So if you think about a tumor, this solid organ in particular,
tumor, this solid organ in particular, well, it needs blood supply. It needs
well, it needs blood supply. It needs oxygen. It needs precursors for
oxygen. It needs precursors for nutrition fuel just like any other organ
nutrition fuel just like any other organ needs. So it generates its own vascular
needs. So it generates its own vascular network inside there to feed itself. And
network inside there to feed itself. And so if you theoretically, you know, block
so if you theoretically, you know, block off or blunt the uh vascule going into
off or blunt the uh vascule going into these particular organs, well then they
these particular organs, well then they won't get their blood supply adequately
won't get their blood supply adequately and then therefore obviously may not be
and then therefore obviously may not be able to grow or expand. Well, then if
able to grow or expand. Well, then if you're targeting something that affects
you're targeting something that affects blood vessel formation and growth and
blood vessel formation and growth and expression, then you're obviously going
expression, then you're obviously going to have problems that relate to, you
to have problems that relate to, you know, bleeding and wounds and things
know, bleeding and wounds and things like that that sort of just make sense.
like that that sort of just make sense. You're impacting the potential
You're impacting the potential cardiovascular system in some way. So I
cardiovascular system in some way. So I we wanted to at least highlight on a
we wanted to at least highlight on a higher level the basics of some of these
higher level the basics of some of these and some of these targets so that you
and some of these targets so that you can recognize why some of these side
can recognize why some of these side effects that you see with VEGF u you
effects that you see with VEGF u you know uh inhibitors here receptor
know uh inhibitors here receptor blockers here that you you would see
blockers here that you you would see some of these reactions seem to make
some of these reactions seem to make sense. Um you put two and two together
sense. Um you put two and two together then it and it sort of shows up. So when
then it and it sort of shows up. So when you monoconal antibodies come from
you monoconal antibodies come from different sources, you need to consider
different sources, you need to consider that um you need to consider the dosing
that um you need to consider the dosing route of administration and then a lot
route of administration and then a lot of these uh because if if they are
of these uh because if if they are coming from a a nonhuman source could
coming from a a nonhuman source could potentially cause you know reactions.
potentially cause you know reactions. Okay. So Allison and Beth any particular
Okay. So Allison and Beth any particular and I go back to any particular slide or
and I go back to any particular slide or you know if you just want to make
you know if you just want to make general con any comments about this
general con any comments about this class of drugs. Um see I don't think
class of drugs. Um see I don't think yeah because it's tyroscene kinase
yeah because it's tyroscene kinase inhibitors is next.
inhibitors is next. >> Yeah I mean this is obviously a very
>> Yeah I mean this is obviously a very very very very diverse set of drugs as
very very very diverse set of drugs as you kind of outlined with the tables the
you kind of outlined with the tables the different targets the different source
different targets the different source of the ano the antibbody whether it's
of the ano the antibbody whether it's humanized or murine or whatever the
humanized or murine or whatever the source is has a huge impact on what the
source is has a huge impact on what the drug is used for and what side effects
drug is used for and what side effects you've got. So I think the slides kind
you've got. So I think the slides kind of nicely summarize a lot of those key
of nicely summarize a lot of those key points and like Tony said just kind of
points and like Tony said just kind of rationally think about what the target
rationally think about what the target is. So VEF we're thinking about
is. So VEF we're thinking about angioenesis. So you should always think
angioenesis. So you should always think about bleeding um as being one of the
about bleeding um as being one of the main side effects with it. Um so I think
main side effects with it. Um so I think this bevicismab being the kind of
this bevicismab being the kind of original drug in this class is worth
original drug in this class is worth talking about a little bit more. So
talking about a little bit more. So bleeding like I said on the flip side
bleeding like I said on the flip side clotting is another issue. see run both
clotting is another issue. see run both sides with that. Kidney damage is
sides with that. Kidney damage is certainly a concern. So we check for
certainly a concern. So we check for protein ura commonly in patients who are
protein ura commonly in patients who are on these drugs. And then GI perforation
on these drugs. And then GI perforation and wounds are two other huge side
and wounds are two other huge side effects. So you figure a lot of these
effects. So you figure a lot of these patients there is that risk of GI
patients there is that risk of GI perforation. But you can't operate on
perforation. But you can't operate on these patients for a month before a
these patients for a month before a month after their dose because of
month after their dose because of bleeding risk and wound dehissence. Um
bleeding risk and wound dehissence. Um so these patients can get into some
so these patients can get into some serious trouble that they need surgery
serious trouble that they need surgery and can't get it um because of those
and can't get it um because of those risks. So it's a double-edged sword
risks. So it's a double-edged sword certainly with this class of drug. Um
certainly with this class of drug. Um the other key one to review that um we
the other key one to review that um we didn't go through in these slides for
didn't go through in these slides for the sake of time I think is the
the sake of time I think is the amunotherapies. So the PD1s and PDL1
amunotherapies. So the PD1s and PDL1 drugs huge huge area of growth. I don't
drugs huge huge area of growth. I don't know if there's a single cancer type at
know if there's a single cancer type at this point that you can't treat with
this point that you can't treat with amunotherapy. It's kind of the wave of
amunotherapy. It's kind of the wave of the future. Um, so with those, just to
the future. Um, so with those, just to briefly touch on them, always thinking
briefly touch on them, always thinking about what they're doing again. So these
about what they're doing again. So these drugs are revving up the immune system
drugs are revving up the immune system to try and fight off the tumor. So you
to try and fight off the tumor. So you see pretty much every itis that you
see pretty much every itis that you could think of, thyroiditis,
could think of, thyroiditis, um, hepatitis,
um, hepatitis, skin rashes,
skin rashes, >> you name it. If it has itis at the end,
>> you name it. If it has itis at the end, it could be caused by imunotherapy. Um,
it could be caused by imunotherapy. Um, so big deal to review those as well.
so big deal to review those as well. >> Yeah. I mean when you reconstitute the
>> Yeah. I mean when you reconstitute the immune system where you overly activate
immune system where you overly activate it, it can be problematic. Um I mean you
it, it can be problematic. Um I mean you see that with sepsis. I mean it's a
see that with sepsis. I mean it's a disregulation of the immune response to
disregulation of the immune response to an infectious process. When you think
an infectious process. When you think about um even COVID and some of the
about um even COVID and some of the complications that occurred from that,
complications that occurred from that, it's partly due to the immune response
it's partly due to the immune response to it. And if you think about some of
to it. And if you think about some of the targets that have been explored, um
the targets that have been explored, um they're trying to blunt some of that um
they're trying to blunt some of that um response to it. So, it's it's very
response to it. So, it's it's very interesting that we sometimes we overly
interesting that we sometimes we overly activate the immune system, it creates a
activate the immune system, it creates a double-edged sword. Um now, the other
double-edged sword. Um now, the other thing that Allison, you mentioned about
thing that Allison, you mentioned about the surgery, which I think is an
the surgery, which I think is an excellent point and could be a
excellent point and could be a counseling point. Um you said was it a
counseling point. Um you said was it a month before and a month after? Is that
month before and a month after? Is that is that what you said? Yes.
is that what you said? Yes. >> Okay. So, part of that I think is
>> Okay. So, part of that I think is related to the fact that monocone
related to the fact that monocone antibodies just like our own antibodies
antibodies just like our own antibodies that we make in our body stick around
that we make in our body stick around for a long time. They have huge half-
for a long time. They have huge half- livives.
livives. >> Um, and I suspect that that's, you know,
>> Um, and I suspect that that's, you know, part of the problem. And if someone does
part of the problem. And if someone does go to surgery and they have one of these
go to surgery and they have one of these drugs, it might have been infused, you
drugs, it might have been infused, you know, two or three weeks ago, but the
know, two or three weeks ago, but the reality is that drug is still present.
reality is that drug is still present. And so when you look at woundistance,
And so when you look at woundistance, wound and impaired healing, well that to
wound and impaired healing, well that to repair something, you have to have blood
repair something, you have to have blood flow to it.
flow to it. >> Um, and you want adequate blood flow
>> Um, and you want adequate blood flow with the precursors being delivered. It
with the precursors being delivered. It doesn't matter. So we used to see this
doesn't matter. So we used to see this same problem with rimatoid patients and
same problem with rimatoid patients and ulcerative colitis patients that used to
ulcerative colitis patients that used to get inflammab infusions. um they they
get inflammab infusions. um they they were a high risk not only risk of
were a high risk not only risk of activating latent TB if it was not
activating latent TB if it was not looked for but on top of that secondary
looked for but on top of that secondary they they couldn't go to surgery uh for
they they couldn't go to surgery uh for weeks uh because of the ability
weeks uh because of the ability inability to um basically heal.
inability to um basically heal. Excellent. So big class growing lots of
Excellent. So big class growing lots of little issues um there. Moving on to the
little issues um there. Moving on to the tyrrosine kinase um inhibitors. Um so
tyrrosine kinase um inhibitors. Um so again very unique uh bio targeting
again very unique uh bio targeting biochemical pathways um that are rather
biochemical pathways um that are rather specific but you see that they also
specific but you see that they also target similar pathways that are also
target similar pathways that are also with the monocone antibodies again the
with the monocone antibodies again the epidermal growth factor receptor um
epidermal growth factor receptor um modulation and then the vascular
modulation and then the vascular endothelial growth factor receptor
endothelial growth factor receptor modulation
modulation um excuse me um here. So again you don't
um excuse me um here. So again you don't have to reinvent the wheel. It's not
have to reinvent the wheel. It's not rocket science. the side effects are
rocket science. the side effects are carried over um for the most part. Um so
carried over um for the most part. Um so just you know keep that in mind. Now
just you know keep that in mind. Now these agents are administered orally. Um
these agents are administered orally. Um they end in nib so that kind of helps
they end in nib so that kind of helps you to put them in the you know the end
you to put them in the you know the end of the name kind of helps you know
of the name kind of helps you know recognition. Um there's a couple other
recognition. Um there's a couple other little pearls that are listed here that
little pearls that are listed here that they are substrates of 3A4. Many of them
they are substrates of 3A4. Many of them cause drug drug interactions. There are
cause drug drug interactions. There are concerns about QT prolongation and
concerns about QT prolongation and certainly if patients with underlying
certainly if patients with underlying electrolyte abnormalities that can
electrolyte abnormalities that can certainly worsen that. So you when you
certainly worsen that. So you when you see somebody with QT prolongation, you
see somebody with QT prolongation, you know, their QT interval is over 450 and
know, their QT interval is over 450 and definitely over 500, then you want to
definitely over 500, then you want to think about all the drugs that could be
think about all the drugs that could be causing that as well as other underlying
causing that as well as other underlying treat uh risk factors like the
treat uh risk factors like the electrolyte abnormalities that I've
electrolyte abnormalities that I've mentioned, hypocalcemia,
mentioned, hypocalcemia, hypocalemia, hypomagnesmia, all those
hypocalemia, hypomagnesmia, all those things can do that. We know that some
things can do that. We know that some fuicquinolones do that. Certain um
fuicquinolones do that. Certain um macrolytes can do that. I mean there's
macrolytes can do that. I mean there's just handfuls of drugs that we have to
just handfuls of drugs that we have to think through um in this class would
think through um in this class would kind of fall into that as well. And then
kind of fall into that as well. And then you know we try to point out here for
you know we try to point out here for the VEGAF and endothelial growth factors
the VEGAF and endothelial growth factors again you still see a lot of the very
again you still see a lot of the very similar. So if you can memorize those
similar. So if you can memorize those associated with the mechanism then it
associated with the mechanism then it makes it much easier to um uh consider
makes it much easier to um uh consider on exams. And then lastly is absorption
on exams. And then lastly is absorption of medications. Obviously if you you
of medications. Obviously if you you need these medications for a reason. So
need these medications for a reason. So just like with antifungal agents like
just like with antifungal agents like you know itriconazol and ketoconazol
you know itriconazol and ketoconazol require acidic environment for adequate
require acidic environment for adequate absorption you know you've got drugs in
absorption you know you've got drugs in this class that have the same problem.
this class that have the same problem. So a simple you know ant acid could
So a simple you know ant acid could theoretically reduce the um efficacy of
theoretically reduce the um efficacy of the drugs. anything else that you guys
the drugs. anything else that you guys want to add in here before we kind of
want to add in here before we kind of move on to the last um segment of
move on to the last um segment of topics?
topics? >> Yeah, I think um while not my area of
>> Yeah, I think um while not my area of expertise with your EGFR inhibitors,
expertise with your EGFR inhibitors, that rash is really common and it's
that rash is really common and it's actually associated with efficacy. So
actually associated with efficacy. So most of the time side effects and
most of the time side effects and efficacy don't correlate, but with your
efficacy don't correlate, but with your EGFR agents that actually is associated
EGFR agents that actually is associated with efficacy. So, if your patient gets
with efficacy. So, if your patient gets a rash after charting, there's a good
a rash after charting, there's a good chance it means it's working. Um, so I
chance it means it's working. Um, so I think that's kind of a neat tidbit to
think that's kind of a neat tidbit to point out. Um, and I do like that you
point out. Um, and I do like that you brought up obviously the
brought up obviously the environment for a lot of the TKI. Um,
environment for a lot of the TKI. Um, that's a big issue with a lot of ours
that's a big issue with a lot of ours for like CML and things like that that
for like CML and things like that that patients are taking protonics and then
patients are taking protonics and then we see their BCR ABLE starting to rise
we see their BCR ABLE starting to rise because their datib is no longer as
because their datib is no longer as effective. So, patients need to be
effective. So, patients need to be counseledled not to take it with that.
counseledled not to take it with that. Um and if they need something they can
Um and if they need something they can take something like uh fotedine you know
take something like uh fotedine you know two hours before two hours after but we
two hours before two hours after but we need to separate it from their TKI.
need to separate it from their TKI. >> Excellent. Yeah. And guys I mean think
>> Excellent. Yeah. And guys I mean think about think about ant acids especially
about think about ant acids especially proton pump inhibitors now that many of
proton pump inhibitors now that many of them uh are available over the counter
them uh are available over the counter without a prescription. I mean patients
without a prescription. I mean patients don't need to talk to anybody to get
don't need to talk to anybody to get them. They're at they're at the
them. They're at they're at the checkouts. They're in the aisles right
checkouts. They're in the aisles right there in front of you. And so many
there in front of you. And so many people are on ant acids and PPIs that
people are on ant acids and PPIs that it's almost like
it's almost like >> gosh, if you're not on a PPI,
>> gosh, if you're not on a PPI, something's wrong with you, right? I
something's wrong with you, right? I mean, they're just so common that we
mean, they're just so common that we sometimes like when we're doing
sometimes like when we're doing medication use evaluations, we just blow
medication use evaluations, we just blow right past them like they they're
right past them like they they're irrelevant.
irrelevant. They're actually very relevant, you
They're actually very relevant, you know, and not only in cytochrome P450
know, and not only in cytochrome P450 mediated inhibition pathways. We know
mediated inhibition pathways. We know that with truth with like lancresol and
that with truth with like lancresol and omipresol with clitigril and pragril we
omipresol with clitigril and pragril we you know I mean you got this example
you know I mean you got this example here think about HIV adanavir
here think about HIV adanavir clearly requires an acidic environment
clearly requires an acidic environment for its absorption you have your um uh
for its absorption you have your um uh the oral formulation ofol that's not the
the oral formulation ofol that's not the solution needs an acidic environment I
solution needs an acidic environment I mean if you're onol you need it that
mean if you're onol you need it that that's not something like you just
that's not something like you just willy-nilly use it's not for your
willy-nilly use it's not for your toenail fungus uh even though you can
toenail fungus uh even though you can use it chronic comicosis, but if you're
use it chronic comicosis, but if you're on oral flu, uh, atroconol, there's a
on oral flu, uh, atroconol, there's a problem. So, you don't want these simple
problem. So, you don't want these simple everyday over-the-counter drugs now to
everyday over-the-counter drugs now to change the efficacy of something that
change the efficacy of something that could be catastrophic um, and
could be catastrophic um, and devastating. Oh, by the way, I'm sorry,
devastating. Oh, by the way, I'm sorry, your cancer is back because you took,
your cancer is back because you took, you know, we gave you the wrong antacid.
you know, we gave you the wrong antacid. I mean, seriously, uh, to me, those are
I mean, seriously, uh, to me, those are like can't miss those kind of things u
like can't miss those kind of things u because they're devastating to patient
because they're devastating to patient outcomes. All right, let's move on to,
outcomes. All right, let's move on to, you know, again, we're going to just hit
you know, again, we're going to just hit the high points here. There's a lot that
the high points here. There's a lot that goes on with some of these chemotherapy
goes on with some of these chemotherapy induced things. We've already talked a
induced things. We've already talked a little bit about like, for example,
little bit about like, for example, cyplatin being one of the more heaggenic
cyplatin being one of the more heaggenic drugs and a lot of things seem to, you
drugs and a lot of things seem to, you know, kind of point to it as a
know, kind of point to it as a comparison. How bad is it? Um, and it
comparison. How bad is it? Um, and it and and there's obviously risk factors,
and and there's obviously risk factors, but there's also different types of
but there's also different types of nausea, vomiting. Uh, it's they're not
nausea, vomiting. Uh, it's they're not all the same. And if you look right here
all the same. And if you look right here in the second, you know, the clinical
in the second, you know, the clinical presentation, we have the sorry my
presentation, we have the sorry my cursors kind of died. No, acute, you
cursors kind of died. No, acute, you know, which occurs within around that
know, which occurs within around that four to six hour window and can last up
four to six hour window and can last up to 24 hours. You got your delayed, which
to 24 hours. You got your delayed, which means it comes on a little bit later.
means it comes on a little bit later. Um, and it peaks a little bit later. And
Um, and it peaks a little bit later. And then you have your anticipatory and then
then you have your anticipatory and then obviously breakthrough and then
obviously breakthrough and then refractory. So, you know, you have to
refractory. So, you know, you have to kind of consider this based on the type
kind of consider this based on the type of regimen that they're on. Uh and then
of regimen that they're on. Uh and then recognize obviously the complications
recognize obviously the complications that can happen, which is what I see. Um
that can happen, which is what I see. Um I mean, I can't tell you how many breast
I mean, I can't tell you how many breast cancer patients I've had come into the
cancer patients I've had come into the emergency department with uncontrolled
emergency department with uncontrolled breakthrough nausea, vomiting that
breakthrough nausea, vomiting that require multiple liters, and sometimes I
require multiple liters, and sometimes I just have to admit them because they
just have to admit them because they have electrolyte deficiency. and and
have electrolyte deficiency. and and they seem to be a little bit more common
they seem to be a little bit more common of a group that I see on my side on the
of a group that I see on my side on the emergency medicine side of things. But,
emergency medicine side of things. But, you know, it's so you have to think
you know, it's so you have to think about the patient population that's
about the patient population that's impacted, the type of drugs are being
impacted, the type of drugs are being used, and then what type of of nausea,
used, and then what type of of nausea, vomiting that you're um doing. So Alison
vomiting that you're um doing. So Alison Beth, when you guys deal with this or
Beth, when you guys deal with this or when you anticipate um these regimens
when you anticipate um these regimens for different indications, which you
for different indications, which you guys represent a number of different
guys represent a number of different areas,
areas, is there a process that you you can
is there a process that you you can guide us that would make it um a little
guide us that would make it um a little bit easy or you have some basic
bit easy or you have some basic recommendations of must know um regimens
recommendations of must know um regimens or combinations that you're probably
or combinations that you're probably gonna they're probably going to see?
gonna they're probably going to see? >> Yeah. So NCCN or ASCO both have very
>> Yeah. So NCCN or ASCO both have very nice guidelines for basically a scoring
nice guidelines for basically a scoring system of high amogenic potential,
system of high amogenic potential, moderate, low, minimal. And those are
moderate, low, minimal. And those are true for IV and oral therapies. And
true for IV and oral therapies. And within those guidelines, they give you
within those guidelines, they give you specifics on how to kind of prophylax as
specifics on how to kind of prophylax as well as provide some breakthrough
well as provide some breakthrough coverage based on the ametic potential
coverage based on the ametic potential of the regimen. So for the most part
of the regimen. So for the most part you're going to have a regimen that's
you're going to have a regimen that's given as premedication about 30 minutes
given as premedication about 30 minutes 60 minutes prior to the chemotherapy up
60 minutes prior to the chemotherapy up front and then most of these regimens
front and then most of these regimens are going to include two to three
are going to include two to three additional days of prophylactic
additional days of prophylactic antiimetics and then like I said a
antiimetics and then like I said a breakthrough agent as well. So it's
breakthrough agent as well. So it's usually a combination of different
usually a combination of different mechanisms of action which some of those
mechanisms of action which some of those are listed down there at the bottom. So
are listed down there at the bottom. So an NK1 like phospatitant, a prepotent
an NK1 like phospatitant, a prepotent for example is really what I describe to
for example is really what I describe to patients as the big gun antic. So that's
patients as the big gun antic. So that's included for your high and some moderate
included for your high and some moderate patients. And then generally
patients. And then generally dexamethasone and a 5HT3 antagonist are
dexamethasone and a 5HT3 antagonist are the other most common prophylactic
the other most common prophylactic regimens that are used again generally
regimens that are used again generally in combination with two to three two
in combination with two to three two really agents at this point.
really agents at this point. >> Excellent. All right. And why I mean
>> Excellent. All right. And why I mean what about the serotonin and receptor
what about the serotonin and receptor anticate I mean that's where most of the
anticate I mean that's where most of the stuff right originated if I'm not
stuff right originated if I'm not mistaken and we we now use zopran like
mistaken and we we now use zopran like it's candy
it's candy >> uh and every every anytime somebody's
>> uh and every every anytime somebody's nauseous for anything. So when we think
nauseous for anything. So when we think about combination like if someone's
about combination like if someone's having if they're on a highly a
having if they're on a highly a metagenic well let me step back a
metagenic well let me step back a second. Do we do you guys think
second. Do we do you guys think that the
that the people not for BCOP really probably have
people not for BCOP really probably have to know all the different categories of
to know all the different categories of it like what dose and what drugs are
it like what dose and what drugs are moderate high? Do I I have not perceived
moderate high? Do I I have not perceived that to be true?
that to be true? >> No, I don't think outside of BOP that
>> No, I don't think outside of BOP that you would be expected to know which
you would be expected to know which drugs fall in the different categories.
drugs fall in the different categories. I think like we've said a few times
I think like we've said a few times cyplatin is kind of your gold standard
cyplatin is kind of your gold standard worst case scenario of a high amigenic
worst case scenario of a high amigenic risk chemotherapy.
risk chemotherapy. >> So I think basically knowing generally
>> So I think basically knowing generally what classes are used would be helpful.
what classes are used would be helpful. >> Okay to explain a little bit further
>> Okay to explain a little bit further into the combinations and the timing of
into the combinations and the timing of some of these different things. If we
some of these different things. If we look at the pathophysiology of
look at the pathophysiology of chemoinduced nausea and vomiting one of
chemoinduced nausea and vomiting one of the first neurotransmitters that's
the first neurotransmitters that's affected is serotonin. So oftentimes the
affected is serotonin. So oftentimes the 5HT3s are used a little bit earlier on
5HT3s are used a little bit earlier on in kind of your more acute setting
in kind of your more acute setting whereas later on we see more dopamine
whereas later on we see more dopamine being the primary neurotransmitter
being the primary neurotransmitter driving the delayed process. So that's
driving the delayed process. So that's why for most of our regimens for
why for most of our regimens for breakthrough we prescribe prochlorazine
breakthrough we prescribe prochlorazine um to try and hit the different
um to try and hit the different mechanisms at the different time points
mechanisms at the different time points after chemotherapy.
after chemotherapy. >> Okay. And then for anticipatory, you
>> Okay. And then for anticipatory, you know, we were I mean I was always taught
know, we were I mean I was always taught and sort of seems like any kind of book
and sort of seems like any kind of book you pick up that's always a benzoazipene
you pick up that's always a benzoazipene or anxolytic agent. Is that still true?
or anxolytic agent. Is that still true? >> Yep.
>> Yep. >> Yep.
>> Yep. That's usually your best case. It's kind
That's usually your best case. It's kind of cheesy to say, but really your best
of cheesy to say, but really your best prevention for anticipatory nausea and
prevention for anticipatory nausea and vomiting is to prevent them from having
vomiting is to prevent them from having nausea and vomiting with the first
nausea and vomiting with the first cycle. That's like the copout answer.
cycle. That's like the copout answer. But if they don't have nausea, then
But if they don't have nausea, then they're not afraid of having nausea next
they're not afraid of having nausea next time. Um,
time. Um, >> but even if the patient doesn't say
>> but even if the patient doesn't say they're anxious and nothing else is
they're anxious and nothing else is working, sometimes a little bit of
working, sometimes a little bit of larazzipam can do wonders for their
larazzipam can do wonders for their nausea.
nausea. >> It's a very real thing that people will
>> It's a very real thing that people will start vomiting once they get to the
start vomiting once they get to the parking lot or once they've walked into
parking lot or once they've walked into the building. A little does wonders. We
the building. A little does wonders. We have a fair number of patients that we
have a fair number of patients that we prescribe it to take on the morning of
prescribe it to take on the morning of chemotherapy because like that said, if
chemotherapy because like that said, if they come in nauseous, they're probably
they come in nauseous, they're probably going to leave nauseous and be nauseous
going to leave nauseous and be nauseous for a while. So, if we could limit that
for a while. So, if we could limit that cycle from happening, it really impacts
cycle from happening, it really impacts them.
them. >> Yeah. I never forgot the case where this
>> Yeah. I never forgot the case where this lady told me that she, you know, she had
lady told me that she, you know, she had been going through chemo and she
been going through chemo and she suffered from this bad and she was in
suffered from this bad and she was in the uh grocery store, felt completely
the uh grocery store, felt completely normal, but her oncologist
normal, but her oncologist came up to her in the aisle and just
came up to her in the aisle and just said hi and she vomited on him. Like
said hi and she vomited on him. Like >> that's how bad it like associated her
>> that's how bad it like associated her experience that she just immediately got
experience that she just immediately got sick. Not because obviously, you know,
sick. Not because obviously, you know, she felt bad, but I remember when she
she felt bad, but I remember when she told me that I was like, "Dear God, I
told me that I was like, "Dear God, I mean, that is that's bad. Poor guy."
mean, that is that's bad. Poor guy." >> Yeah.
>> Yeah. >> But but it just it you know, not to
>> But but it just it you know, not to laugh because nobody wants to have a a
laugh because nobody wants to have a a patient experience that, but that's how
patient experience that, but that's how psychologically influential this is. and
psychologically influential this is. and um that it re registers that that
um that it re registers that that severe. Excellent. Okay, let's move on
severe. Excellent. Okay, let's move on to uh chemotherapy induced diarrhea and
to uh chemotherapy induced diarrhea and kind of what we do for these. Um you've
kind of what we do for these. Um you've heard that we talked about 5FU as a
heard that we talked about 5FU as a reminder. We talked about uh Iron Tan
reminder. We talked about uh Iron Tan and I ran to the can, you know, just to,
and I ran to the can, you know, just to, you know, remember that. And then I
you know, remember that. And then I mentioned on the summary slide that your
mentioned on the summary slide that your tyrroscine kind inhibitors seem to all
tyrroscine kind inhibitors seem to all relatively be associated with it. But
relatively be associated with it. But there's different grades just like with
there's different grades just like with you know the degrees of edit
you know the degrees of edit metagenicity of the drugs. Uh there's
metagenicity of the drugs. Uh there's different grades or severity of the
different grades or severity of the diarrhea. Um those are listed here as
diarrhea. Um those are listed here as sort of uncomplicated being grade one
sort of uncomplicated being grade one and two versus complicated being more
and two versus complicated being more grade three and four. And so obviously
grade three and four. And so obviously drugs like F5FU arenotic are more likely
drugs like F5FU arenotic are more likely um to see that. So what do we do for
um to see that. So what do we do for these patients? Um is it just low
these patients? Um is it just low paramide or other options? And what do
paramide or other options? And what do you guys recommend that we know?
you guys recommend that we know? >> So low paramides always kind of your
>> So low paramides always kind of your starting point at least for most of my
starting point at least for most of my patients. Um if you're on the BMT floor,
patients. Um if you're on the BMT floor, we also rule out any infections. We make
we also rule out any infections. We make sure it's not C diff or anything like
sure it's not C diff or anything like that. Um probably not as common in the
that. Um probably not as common in the outpatient world, but we do our due
outpatient world, but we do our due diligence with our BMT folks for sure.
diligence with our BMT folks for sure. Um, so lamide is always a good starting
Um, so lamide is always a good starting point and making sure that patients are
point and making sure that patients are hydrated. They probably need a couple
hydrated. They probably need a couple liters of IV fluid if they've been
liters of IV fluid if they've been having really severe diarrhea at home
having really severe diarrhea at home for a couple days. If leramide doesn't
for a couple days. If leramide doesn't cut it, you can try lamodal or alternate
cut it, you can try lamodal or alternate the two. So sometimes I have patients on
the two. So sometimes I have patients on it, you know, every two hours they're
it, you know, every two hours they're taking one of those agents.
taking one of those agents. >> Um, from there you would move into
>> Um, from there you would move into something like probably tincture of
something like probably tincture of opium or triotide. So
opium or triotide. So we can get some really bad diarrhea on
we can get some really bad diarrhea on the BMT floor for sure from our chemo.
the BMT floor for sure from our chemo. So tincture of opium is not something we
So tincture of opium is not something we move to lightly, but that's kind of our
move to lightly, but that's kind of our absolute last line. Like worst case
absolute last line. Like worst case scenario, we can't get this under
scenario, we can't get this under control.
control. >> I think on the outpatient setting, a key
>> I think on the outpatient setting, a key is to encourage patients to use these
is to encourage patients to use these drugs early and often. I think a lot of
drugs early and often. I think a lot of patients worry about constipation. And
patients worry about constipation. And so a lot of our patients who are older,
so a lot of our patients who are older, for example, might say like, "Oh, I'd
for example, might say like, "Oh, I'd rather have a little diarrhea than swing
rather have a little diarrhea than swing the other way, so I'm just going to wait
the other way, so I'm just going to wait it out and see what happens."
it out and see what happens." >> Not a good idea. We have a number of
>> Not a good idea. We have a number of patients that say the emodium doesn't
patients that say the emodium doesn't work or because they took one dose and
work or because they took one dose and stopped. So you have to really reiterate
stopped. So you have to really reiterate as it says on the packaging, you know,
as it says on the packaging, you know, take two with the first loose stool and
take two with the first loose stool and then keep taking it with each subsequent
then keep taking it with each subsequent one because it really does. somebody
one because it really does. somebody taking leramide as they're supposed to
taking leramide as they're supposed to makes a world of difference versus
makes a world of difference versus somebody who took it once and hope.
somebody who took it once and hope. >> That's excellent feedback. Yeah. And do
>> That's excellent feedback. Yeah. And do you guys uh are there any situations or
you guys uh are there any situations or do you do you counsel these patients to
do you do you counsel these patients to stop at 16 milligrams traditional
stop at 16 milligrams traditional teaching you know of the of the dosing
teaching you know of the of the dosing limitation or do you can you go higher
limitation or do you can you go higher than that in some of these patients?
than that in some of these patients? >> You can go higher than that in some of
>> You can go higher than that in some of the patients. Um, we don't often do
the patients. Um, we don't often do that. We prefer to do like what Beth
that. We prefer to do like what Beth said and alternate between
said and alternate between >> Yeah. Okay.
>> Yeah. Okay. >> the other agents as well. But yes, you
>> the other agents as well. But yes, you can
can >> certainly go up higher in these patients
>> certainly go up higher in these patients that 16 milligram warning becomes more
that 16 milligram warning becomes more like 32 in some cases.
like 32 in some cases. >> Okay. So, and then the antibiotics that
>> Okay. So, and then the antibiotics that sound like you know that if there was an
sound like you know that if there was an infectious reason so that was like the
infectious reason so that was like the bone marrow transplant you you're you're
bone marrow transplant you you're you're considering CIFF kind of in that
considering CIFF kind of in that situation.
situation. Um and then octriotide would really only
Um and then octriotide would really only be as refractory that that opium
be as refractory that that opium tincture of opium and then octriotide if
tincture of opium and then octriotide if they're not responding to um anything
they're not responding to um anything else. Okay. What about febal
else. Okay. What about febal neutropenia? So we know that these drugs
neutropenia? So we know that these drugs can wipe out certain cell lines and you
can wipe out certain cell lines and you know obviously neutropenia is a fairly
know obviously neutropenia is a fairly common term these and our immune system
common term these and our immune system is necessary for us to fight infections.
is necessary for us to fight infections. So we put, you know, some of the
So we put, you know, some of the criteria down here. Um, and especially,
criteria down here. Um, and especially, you know, I think there's different
you know, I think there's different grades of neutropenia as well, right?
grades of neutropenia as well, right? There's, uh, different intervals that
There's, uh, different intervals that you go, but once you get less than 500,
you go, but once you get less than 500, uh, with a fever, um, then that's
uh, with a fever, um, then that's obviously our concern. So, walk us
obviously our concern. So, walk us through like if you guys have a patient,
through like if you guys have a patient, you know, what what what is the approach
you know, what what what is the approach to management that we should consider?
to management that we should consider? or is it just like a septic patient and
or is it just like a septic patient and you get blood cultures and start them on
you get blood cultures and start them on a pair of antibiotics? And
a pair of antibiotics? And >> so mine and Allison's answers are going
>> so mine and Allison's answers are going to be very different based on the
to be very different based on the patient populations that we treat.
patient populations that we treat. >> When you think about feal neutropenia,
>> When you think about feal neutropenia, urine BMT patients are going to be high
urine BMT patients are going to be high risk. They are neutropenic for sometimes
risk. They are neutropenic for sometimes weeks on end um with a white count of
weeks on end um with a white count of absolutely zero. So when you look at any
absolutely zero. So when you look at any of the high-risisk, low-risisk feal
of the high-risisk, low-risisk feal neutropenia scores, my patients are
neutropenia scores, my patients are always high. So for them, unfortunately,
always high. So for them, unfortunately, a fever almost always buys you a
a fever almost always buys you a hospital admission. You're going to have
hospital admission. You're going to have to come in and see me. We're going to
to come in and see me. We're going to hook you up to IV antibiotics. Um it's
hook you up to IV antibiotics. Um it's kind of non-negotiable. Fever can be the
kind of non-negotiable. Fever can be the only sign of infection in someone who
only sign of infection in someone who has a non-existent white blood cell
has a non-existent white blood cell count. They're not going to generate
count. They're not going to generate pus. Their pneumonia isn't going to show
pus. Their pneumonia isn't going to show or might not show anything on the chest
or might not show anything on the chest X-ray because that cloudiness is white
X-ray because that cloudiness is white blood cells and they don't have any of
blood cells and they don't have any of those. So
those. So >> they get admitted. The most important
>> they get admitted. The most important thing is they need some sort of
thing is they need some sort of anti-studamonal therapy. Um, gram
anti-studamonal therapy. Um, gram negatives are always going to kill you
negatives are always going to kill you faster than gram positives. So if they
faster than gram positives. So if they only have one line, for some reason you
only have one line, for some reason you can't do multiple antibiotics at once,
can't do multiple antibiotics at once, the gram negative coverage is always
the gram negative coverage is always most important to get in first. As long
most important to get in first. As long as they have antiudetamonal coverage, in
as they have antiudetamonal coverage, in most cases, you're okay. If they have
most cases, you're okay. If they have things concerning for skin and soft
things concerning for skin and soft tissue infection, history of MRSA, a
tissue infection, history of MRSA, a pneumonia, you could consider adding
pneumonia, you could consider adding venkcomy as well as if they're
venkcomy as well as if they're hemodynamically unstable. Um, but for
hemodynamically unstable. Um, but for your average patient, something like
your average patient, something like sephopene would be totally adequate for
sephopene would be totally adequate for first-line neutropenic fever therapy in
first-line neutropenic fever therapy in your high-risisk patients. Um, as far as
your high-risisk patients. Um, as far as fungal coverage, it's not usually
fungal coverage, it's not usually empiric upfront in our patients. If I
empiric upfront in our patients. If I have you on sephopene bang for a couple
have you on sephopene bang for a couple days and you're still fevering, that's
days and you're still fevering, that's when I might consider kind of increasing
when I might consider kind of increasing or broadening fungal coverage. Most of
or broadening fungal coverage. Most of the time in neutropenic fever, you're
the time in neutropenic fever, you're not going to find anything. So, we're
not going to find anything. So, we're sometimes treating an infection that may
sometimes treating an infection that may or may not exist. Um, but it's deadly
or may not exist. Um, but it's deadly sometimes if we stop. So, we do tend to
sometimes if we stop. So, we do tend to overtreat. We're not very good
overtreat. We're not very good antibiotic stewards on the hem floor. I
antibiotic stewards on the hem floor. I apologize for my field, but we'll kill
apologize for my field, but we'll kill patients if we pull antibiotics off too
patients if we pull antibiotics off too early. So, we always air on the side of
early. So, we always air on the side of caution.
caution. Yeah. No, that's What about anti- any
Yeah. No, that's What about anti- any viral infections? Antivirals. Is that
viral infections? Antivirals. Is that ever
ever um warranted in an ear patient
um warranted in an ear patient especially with zero?
especially with zero? >> It's not typically empiric neutropenic
>> It's not typically empiric neutropenic fever treatment. Most of my patients if
fever treatment. Most of my patients if they are neutropenic are on like a
they are neutropenic are on like a cycllo antiviral prophylaxis anyways. If
cycllo antiviral prophylaxis anyways. If we had some sort of concern for like a
we had some sort of concern for like a viral menitis absolutely we would go up
viral menitis absolutely we would go up to treatment dose or if we knew we had
to treatment dose or if we knew we had some kind of like HSV outbreak but not
some kind of like HSV outbreak but not typically standard neutropenic fever
typically standard neutropenic fever treatment.
treatment. >> All right. Allison was there anything
>> All right. Allison was there anything different that you would add um since
different that you would add um since that you're kind of a little bit in a
that you're kind of a little bit in a different environment that we wish any
different environment that we wish any pearls that we would need to think about
pearls that we would need to think about other than that?
other than that? It's largely treated the same. I think
It's largely treated the same. I think the main difference just to be aware of
the main difference just to be aware of of what we're talking about the
of what we're talking about the difference between the patient
difference between the patient population is that solid tumor patients
population is that solid tumor patients are generally not as neutropenic and
are generally not as neutropenic and certainly not for as long. So the risk
certainly not for as long. So the risk is much less. We still would treat them.
is much less. We still would treat them. We send them to the emergency room if
We send them to the emergency room if they meet the fever criteria to get labs
they meet the fever criteria to get labs drawn and get cultures drawn, get
drawn and get cultures drawn, get antibiotics started immediately, but
antibiotics started immediately, but they're generally not admitted for very
they're generally not admitted for very long. As Beth pointed out, most of the
long. As Beth pointed out, most of the time these are not true fevers. So in
time these are not true fevers. So in our patients, they usually recover their
our patients, they usually recover their counts in a couple of days once they've
counts in a couple of days once they've kind of gone through their nater. They
kind of gone through their nater. They could be sent out on oral antibiotics
could be sent out on oral antibiotics just to kind of close the loop even if
just to kind of close the loop even if they have negative cultures. But it's
they have negative cultures. But it's it's a much
it's a much >> perfect
>> perfect >> less emergent I would say. So I I hear
>> less emergent I would say. So I I hear you know you know obviously be vigilant
you know you know obviously be vigilant to monitor for these patients counsel
to monitor for these patients counsel the patients and I know that the
the patients and I know that the patients who come in to see me they're
patients who come in to see me they're they were like I I I you know I'm
they were like I I I you know I'm supposed to come in and see you when I
supposed to come in and see you when I have a fever and and you know they're
have a fever and and you know they're they've been counseledled well
they've been counseledled well >> and uh so you can tell when a good
>> and uh so you can tell when a good clinician has been involved and you know
clinician has been involved and you know so we need to be vigilant monitor thatal
so we need to be vigilant monitor thatal coverage is your priority
coverage is your priority um and then obviously if you have
um and then obviously if you have concerns for skin soft tissue MRSA
concerns for skin soft tissue MRSA history, then plus or minus spank, and
history, then plus or minus spank, and then relatively
then relatively rare to use antifungals
rare to use antifungals um as empiric. So, you don't just start
um as empiric. So, you don't just start them on it, even though it sort of you
them on it, even though it sort of you might think it potentially is intuitive.
might think it potentially is intuitive. Um it is not something that you should
Um it is not something that you should see. So, that might be a trick question
see. So, that might be a trick question um or an answer choice on a board exam
um or an answer choice on a board exam is the addition of antivirals, the
is the addition of antivirals, the addition of antifungal agents because
addition of antifungal agents because you think you want to just throw the
you think you want to just throw the whole kitchen sink at them. And in
whole kitchen sink at them. And in reality, remember, you're exposing them
reality, remember, you're exposing them to drugs that have a double-edged sword.
to drugs that have a double-edged sword. You know, yes, if if it's possibly there
You know, yes, if if it's possibly there and you have enough risk factors or a
and you have enough risk factors or a history, then, you know, maybe, but
history, then, you know, maybe, but they're going to it's going to be slam
they're going to it's going to be slam dunk if that's the case. Um so good key
dunk if that's the case. Um so good key points, excellent um thing. I think this
points, excellent um thing. I think this is our last one which is tumor lis
is our last one which is tumor lis syndrome and I think Beth this is your
syndrome and I think Beth this is your your area like your the plague like for
your area like your the plague like for me it was you know COVID and like the
me it was you know COVID and like the you know strokes and MI chest pain was
you know strokes and MI chest pain was never it's tumorizing syndrome is your
never it's tumorizing syndrome is your is probably your bane. Talk to us about
is probably your bane. Talk to us about this and um you know when when would we
this and um you know when when would we see it? What would these what are the
see it? What would these what are the what are these guys going to see on a
what are these guys going to see on a board exam that's going to help them go
board exam that's going to help them go this is what's going on and I need to do
this is what's going on and I need to do this.
this. >> Yeah. So tumorlyisa syndrome is
>> Yeah. So tumorlyisa syndrome is basically when your tumor is dying so
basically when your tumor is dying so fast that all of its intracellular
fast that all of its intracellular contents are released into the patient's
contents are released into the patient's bloodstream. Hence kind of the name
bloodstream. Hence kind of the name tumorly syndrome. It's actually a good
tumorly syndrome. It's actually a good thing. It means our treatment is working
thing. It means our treatment is working but it can kind of wreak havoc on your
but it can kind of wreak havoc on your electrolytes and metabolites in your
electrolytes and metabolites in your body. It is much much much more common
body. It is much much much more common in your hem patients. Your really fast
in your hem patients. Your really fast growing tumors, acute leukemias, some of
growing tumors, acute leukemias, some of your aggressive lymphas are much more
your aggressive lymphas are much more likely to have tumor lysis. Most of
likely to have tumor lysis. Most of those patients are going to be high risk
those patients are going to be high risk and need to be on prophylaxis. On the
and need to be on prophylaxis. On the flip side, there's maybe one or two
flip side, there's maybe one or two solid tumors. I think some of your
solid tumors. I think some of your aggressive lung cancers could be maybe
aggressive lung cancers could be maybe mild moderate risk for tumoris. So it's
mild moderate risk for tumoris. So it's very much kind of a hem focused topic in
very much kind of a hem focused topic in probably 95% of cases. Um most important
probably 95% of cases. Um most important thing with tumoris prophylaxis is
thing with tumoris prophylaxis is fluids. IV fluids I mentioned earlier is
fluids. IV fluids I mentioned earlier is almost always the answer. Um and that's
almost always the answer. Um and that's kind of always our first line treatment
kind of always our first line treatment um to get started as prophylaxis. I
um to get started as prophylaxis. I think it's important to know that
think it's important to know that tumoris can happen spontaneously. So you
tumoris can happen spontaneously. So you can have a patient with a newly
can have a patient with a newly diagnosed malignancy that presents in
diagnosed malignancy that presents in tumoris and patients are at really high
tumoris and patients are at really high risk for it after we start treatment.
risk for it after we start treatment. Typically the first 24 to 48 hours, but
Typically the first 24 to 48 hours, but it could occur technically up to a week
it could occur technically up to a week after starting treatment. After that
after starting treatment. After that point, you're usually pretty safe
point, you're usually pretty safe because any spell cells that were going
because any spell cells that were going to spontaneously lice and die should
to spontaneously lice and die should have done so the minute they were
have done so the minute they were exposed to chemotherapy.
exposed to chemotherapy. So we're very aggressive with our IV
So we're very aggressive with our IV fluids. Um and patients are always put
fluids. Um and patients are always put on aluridol which helps protect your
on aluridol which helps protect your kidneys from uric acid formation. So
kidneys from uric acid formation. So when patients have tumorlyis you're
when patients have tumorlyis you're going to see hyperurysmia from DNA
going to see hyperurysmia from DNA breakdown from those intracellular
breakdown from those intracellular contents hypercalemia so potassium
contents hypercalemia so potassium relation the cells hyperphospatia
relation the cells hyperphospatia phosphate relation in the cells and then
phosphate relation in the cells and then you see hypocalcemia so that's the only
you see hypocalcemia so that's the only one that goes down in tumorlyis and
one that goes down in tumorlyis and that's because that extra phosphate
that's because that extra phosphate binds to the calcium and causes it to go
binds to the calcium and causes it to go down so think about your TPNS and your
down so think about your TPNS and your calcium phosphate precipitation that's
calcium phosphate precipitation that's what happens in tumorlyis as So
what happens in tumorlyis as So >> when did when would you pull the
>> when did when would you pull the raspberase card in a case? Like why
raspberase card in a case? Like why would somebody pull that one out?
would somebody pull that one out? >> So raspierase as evidenced by the name
>> So raspierase as evidenced by the name is an enzyme that can break down uric
is an enzyme that can break down uric acid. Um it can get rid of existing uric
acid. Um it can get rid of existing uric acid whereas alipurol only prevents
acid whereas alipurol only prevents formation of new uric acid. So if
formation of new uric acid. So if someone comes in and their uric acid is
someone comes in and their uric acid is 13 14 15 that's when I kind of start to
13 14 15 that's when I kind of start to think about it. Um, I like to at least
think about it. Um, I like to at least trial IV fluids for a couple hours and
trial IV fluids for a couple hours and see if we can bring it down. But if it's
see if we can bring it down. But if it's not budging or they come in and it's 17
not budging or they come in and it's 17 18, we need to go ahead and give
18, we need to go ahead and give raspberry case. Once patients get rasper
raspberry case. Once patients get rasper case, their blood samples need to be
case, their blood samples need to be kept on ice because that enzyme
kept on ice because that enzyme continues to work even when it's not in
continues to work even when it's not in their body. Uh, but you should pretty
their body. Uh, but you should pretty dramatically see their uric acid come
dramatically see their uric acid come down after that. Just like lucarpace,
down after that. Just like lucarpace, it's expensive. We do keep it on the
it's expensive. We do keep it on the hospital shelf though so we can get that
hospital shelf though so we can get that to you anytime but we try not to give it
to you anytime but we try not to give it unless it's clinically relevant because
unless it's clinically relevant because fluids and alipurol can usually do a
fluids and alipurol can usually do a pretty good job. You want to be really
pretty good job. You want to be really judicious with your electrolyte
judicious with your electrolyte replacement. We don't want to give extra
replacement. We don't want to give extra calcium phosphate and you don't want to
calcium phosphate and you don't want to replete or give K and FOS. You don't
replete or give K and FOS. You don't want to replete calcium unless patients
want to replete calcium unless patients are having symptoms of hypocalcemia
are having symptoms of hypocalcemia because you're going to get it and it's
because you're going to get it and it's just going to bind right to that
just going to bind right to that phosphate again.
phosphate again. >> Yeah. Yeah. Can I uh ask you just a
>> Yeah. Yeah. Can I uh ask you just a random question out of curiosity? Sorry,
random question out of curiosity? Sorry, but uh it if alopurinol have you ever
but uh it if alopurinol have you ever usedat
usedat in this situation ever?
in this situation ever? >> I think I might have used it once in a
>> I think I might have used it once in a patient who claimed they were allergic
patient who claimed they were allergic to alopuranol and couldn't get it. Um
to alopuranol and couldn't get it. Um really all of our data is with alipurol.
really all of our data is with alipurol. So that's what we use. In theory, the
So that's what we use. In theory, the bust should work just fine since they
bust should work just fine since they have the same mechanism of action, but
have the same mechanism of action, but no one ever uses it.
no one ever uses it. >> I also like to point out we don't
>> I also like to point out we don't renally adjust alurol for tumoris. The
renally adjust alurol for tumoris. The biggest side effect of alipurinol is
biggest side effect of alipurinol is potentially a rash and that's not dose
potentially a rash and that's not dose dependent. So the risk and benefits
dependent. So the risk and benefits definitely weighs more in being
definitely weighs more in being aggressive in tumorlyis treatment than
aggressive in tumorlyis treatment than any potential renal dose adjustment. So
any potential renal dose adjustment. So typically you're looking at aluranol 300
typically you're looking at aluranol 300 milligrams two to three times a day
milligrams two to three times a day depending on the institutional
depending on the institutional practices.
practices. >> All right, that is outstanding.
>> All right, that is outstanding. All right, extravisation of
All right, extravisation of chemotherapy. We've talked about a few
chemotherapy. We've talked about a few of these and we we mentioned that a lot
of these and we we mentioned that a lot of these patients have ports for prevent
of these patients have ports for prevent this from happening. Plus we also some
this from happening. Plus we also some we don't want these drugs irritating the
we don't want these drugs irritating the vessels and causing phobitis or
vessels and causing phobitis or infiltrating into the tissue but
infiltrating into the tissue but obviously uh sometimes it can happen. We
obviously uh sometimes it can happen. We briefly mentioned a couple antidotes
briefly mentioned a couple antidotes earlier at the beginning um that you
earlier at the beginning um that you know you would consider using and then
know you would consider using and then you know obviously we stressed stop the
you know obviously we stressed stop the drug um and if you can aspirate out some
drug um and if you can aspirate out some of it from the line or in the IV
of it from the line or in the IV catheter or something if you happen to
catheter or something if you happen to be getting then then do that and even
be getting then then do that and even you know uh decanulate that area if it's
you know uh decanulate that area if it's not a central line and you you know
not a central line and you you know consult with somebody first with
consult with somebody first with obviously doing that but if it's a
obviously doing that but if it's a peripheral line obviously do that and
peripheral line obviously do that and then elevate your traditional things
then elevate your traditional things that you would do for any kind of injury
that you would do for any kind of injury or swelling to tissue. Um do you guys
or swelling to tissue. Um do you guys have anything else that you would add
have anything else that you would add here um that should you know in your
here um that should you know in your management or it might show up on a
management or it might show up on a board
board >> for treatment kind of interestingly cold
>> for treatment kind of interestingly cold compress is the answer for most agents
compress is the answer for most agents but there's actually a number that cold
but there's actually a number that cold can make it worse and you want to use a
can make it worse and you want to use a warm compress so beyond the scope for
warm compress so beyond the scope for this probably but we think of the drugs
this probably but we think of the drugs that are derived from plants mostly easy
that are derived from plants mostly easy way to remember that plants need sun
way to remember that plants need sun warm compress so like the vinka
warm compress so like the vinka alkaloids I always remember that you put
alkaloids I always remember that you put a warm comp compress on for that one
a warm comp compress on for that one rather than a cold.
rather than a cold. >> Oh, that's good. I like that.
>> Oh, that's good. I like that. >> Again, kind of beyond the scope of what
>> Again, kind of beyond the scope of what you would probably be asked, but just
you would probably be asked, but just know that.
know that. >> No, that that seems legit. I don't know.
>> No, that that seems legit. I don't know. That's not that hard to remember.
That's not that hard to remember. >> Not that.
>> Not that. >> All right. Let's see. I think that's it,
>> All right. Let's see. I think that's it, guys. So, we're going to move to the uh
guys. So, we're going to move to the uh we did pretty well on time. So, again,
we did pretty well on time. So, again, we're going to keep this section
we're going to keep this section limited. uh we will be offering a
limited. uh we will be offering a followup uh just pure Q&A session.
followup uh just pure Q&A session. Again, we would recommend and request
Again, we would recommend and request that you send us your questions in
that you send us your questions in advance and um and we'll try to you know
advance and um and we'll try to you know consolidate those or collate them into
consolidate those or collate them into topics um areas and we'll just try to do
topics um areas and we'll just try to do our best to answer them and that'll be
our best to answer them and that'll be uh the next live uh study group Q&A
uh the next live uh study group Q&A session which is free and open to the
session which is free and open to the public. So feel free if you have uh you
public. So feel free if you have uh you know colleagues you're studying with and
know colleagues you're studying with and you guys are struggling with a concept
you guys are struggling with a concept or you want somebody to explain
or you want somebody to explain something again again send it to us that
something again again send it to us that would be really helpful. You can also
would be really helpful. You can also email that to customer service if uh
email that to customer service if uh you're not sure where to submit it but
you're not sure where to submit it but there should be a link also on the uh
there should be a link also on the uh web page for the next session where you
web page for the next session where you can submit a question in advance. Uh we
can submit a question in advance. Uh we always send out a couple days before and
always send out a couple days before and at least the day of asking what your
at least the day of asking what your questions are. And again, that just
questions are. And again, that just allows us to um have an idea. Okay.
allows us to um have an idea. Okay. Um so, let's just go through a couple of
Um so, let's just go through a couple of these questions here. How many how much
these questions here. How many how much peds is typically on the BCOP exam? I'm
peds is typically on the BCOP exam? I'm going to let you guys answer these
going to let you guys answer these questions. um recognizing that uh we
questions. um recognizing that uh we don't want to uh you know we don't ever
don't want to uh you know we don't ever like give specific details of the
like give specific details of the questions that we saw on a test to
questions that we saw on a test to protect the integrity of the exam but
protect the integrity of the exam but just in general like the concept of
just in general like the concept of obviously the the patient population
obviously the the patient population >> I will be honest I studied P zero hours
>> I will be honest I studied P zero hours because I just threw in the towel and
because I just threw in the towel and knew I was not going to get those
knew I was not going to get those questions. Um so they are there it is a
questions. Um so they are there it is a small number um I would say more general
small number um I would say more general topics related to peds rather than
topics related to peds rather than anything like specific regimen um
anything like specific regimen um teaching but I think when you whether
teaching but I think when you whether you're studying for bcop or bcps there's
you're studying for bcop or bcps there's a lot of material um so you kind of have
a lot of material um so you kind of have to be methodical with some of it so I
to be methodical with some of it so I don't know do do what you will but um I
don't know do do what you will but um I didn't have a robust pedes rotation
didn't have a robust pedes rotation experience as a resident And it was a
experience as a resident And it was a large amount of material that I knew I
large amount of material that I knew I was not going to master. So I just put
was not going to master. So I just put the head there. I passed. Don't worry.
the head there. I passed. Don't worry. >> Yeah. Take your lot take and move
>> Yeah. Take your lot take and move forward. Right. I agreed.
forward. Right. I agreed. >> There was a lot of breast cancer on the
>> There was a lot of breast cancer on the BCOP exam. So there was
BCOP exam. So there was >> Beth did Beth, do you have any uh
>> Beth did Beth, do you have any uh feedback on that one? Especially
feedback on that one? Especially >> I had pretty aggressive pets rotations.
>> I had pretty aggressive pets rotations. I did Pete's bone marrow transplant. I
I did Pete's bone marrow transplant. I did two months of pets oncology between
did two months of pets oncology between my general medicine training and
my general medicine training and oncology. So I also didn't study pets
oncology. So I also didn't study pets but I almost took a job in pets. So I'm
but I almost took a job in pets. So I'm not necessarily the best person. But I
not necessarily the best person. But I agree it's a very small portion. Pets
agree it's a very small portion. Pets and bone marrow transplant aren't
and bone marrow transplant aren't focused on a ton. Bone marrow
focused on a ton. Bone marrow transplants a very gray area. There's a
transplants a very gray area. There's a lot of things that differ institution to
lot of things that differ institution to institution. So it's really hard to ask
institution. So it's really hard to ask a ton of specific questions on
a ton of specific questions on transplant regimens because they're not
transplant regimens because they're not standardized across the country. So
standardized across the country. So while the marrow transplant is a
while the marrow transplant is a complicated section, it's not
complicated section, it's not necessarily a huge focus of exam just
necessarily a huge focus of exam just because it doesn't have black and white
because it doesn't have black and white answers.
answers. >> Right. and and you bring up something I
>> Right. and and you bring up something I sound like a broken record and I'm I and
sound like a broken record and I'm I and I appreciate you Beth saying that where
I appreciate you Beth saying that where you enter into an area that isn't
you enter into an area that isn't standard of care across the uh United
standard of care across the uh United States um or that is wellestablished
States um or that is wellestablished those are not great questions guys so if
those are not great questions guys so if you find yourself digging into weeds or
you find yourself digging into weeds or there's debate or the level of evidence
there's debate or the level of evidence or recommend class of recommendation is
or recommend class of recommendation is low then it's probably
low then it's probably going to be a harder question for them
going to be a harder question for them to justify asking um given the uh
to justify asking um given the uh variations and protocols and things. So
variations and protocols and things. So that's thanks for saying that because
that's thanks for saying that because it's actually an excellent point uh
it's actually an excellent point uh especially for noncology related stuff.
especially for noncology related stuff. It's certainly true for that. On the
It's certainly true for that. On the oncology portion of the Q bankank is
oncology portion of the Q bankank is quite lengthy. Uh so I'm answer this one
quite lengthy. Uh so I'm answer this one Amy uh uh there are questions uh mainly
Amy uh uh there are questions uh mainly used for preparation for BCBS. So we on
used for preparation for BCBS. So we on the high yield side when you know first
the high yield side when you know first of all the BCOP Qbank is only written uh
of all the BCOP Qbank is only written uh and those questions only come from BCOP
and those questions only come from BCOP uh certified practicing clinicians
uh certified practicing clinicians period. Nobody else writes those. So we
period. Nobody else writes those. So we trust and involve them for a reason. and
trust and involve them for a reason. and we have a fairly decent uh group of
we have a fairly decent uh group of active uh clinicians for which Allison
active uh clinicians for which Allison and Beth are both um contribute to that.
and Beth are both um contribute to that. So some of the questions that you've
So some of the questions that you've answered are from them. uh but that we
answered are from them. uh but that we for the nonBCOP people we have tried to
for the nonBCOP people we have tried to some people want just enough to get by
some people want just enough to get by and some people want enough more to
and some people want enough more to practice with and dive in a little
practice with and dive in a little deeper and so we have aired on trying to
deeper and so we have aired on trying to give you a little bit more which is why
give you a little bit more which is why it feels lengthy to try to expose you to
it feels lengthy to try to expose you to some of those things and to dig into
some of those things and to dig into those core concepts if you feel like you
those core concepts if you feel like you need it as a it's an area of weakness
need it as a it's an area of weakness again when you think about the exam just
again when you think about the exam just kind of like you heard with pediatrics
kind of like you heard with pediatrics for BCPS and stuff. You're talking about
for BCPS and stuff. You're talking about oncology as a very small segment of this
oncology as a very small segment of this broad exam. Same thing for BCACP, you
broad exam. Same thing for BCACP, you know, that deal with outpatient related
know, that deal with outpatient related patient situations. You know, you're
patient situations. You know, you're talking about a very small portion. So,
talking about a very small portion. So, how much time are you going to dedicate
how much time are you going to dedicate to studying to get that potential one or
to studying to get that potential one or two questions right? It's it's a return
two questions right? It's it's a return on investment question that you have to
on investment question that you have to ask for yourself. As you guys know, our
ask for yourself. As you guys know, our QBank helps you to identify what areas
QBank helps you to identify what areas you're strong in and what areas you're
you're strong in and what areas you're weak in. And so, as you answer
weak in. And so, as you answer questions, if you find that you're
questions, if you find that you're scoring low or missing them, then maybe
scoring low or missing them, then maybe that's something to step back away and
that's something to step back away and go, okay, is this, you know, how much
go, okay, is this, you know, how much time do I want to dedicate with the rest
time do I want to dedicate with the rest of the content that I have to go
of the content that I have to go through? So, you heard, for like
through? So, you heard, for like example, Allison just said, forget it.
example, Allison just said, forget it. I'm just going to miss them because I I
I'm just going to miss them because I I it would take me too long to figure it
it would take me too long to figure it all out uh to answer a few of the
all out uh to answer a few of the questions and I'll make up for other
questions and I'll make up for other areas. So, I hope that answered your
areas. So, I hope that answered your question, Amy. Uh moving on to the let's
question, Amy. Uh moving on to the let's see, next one. Question was for taxane
see, next one. Question was for taxane treatment. Which antihistamines and
treatment. Which antihistamines and steroids are used to premedicate?
steroids are used to premedicate? >> Somewhat based on institutional standard
>> Somewhat based on institutional standard um with that. So it's usually dual
um with that. So it's usually dual antihistamines with an H2RA and your
antihistamines with an H2RA and your typical um antihistamines. So
typical um antihistamines. So dyenhydramines, tyroine, lauratine,
dyenhydramines, tyroine, lauratine, whatever is on formulary and then your
whatever is on formulary and then your um fotedine or whichever H2A is on
um fotedine or whichever H2A is on formulary and then dexamethasone
formulary and then dexamethasone typically being the corticosteroid
typically being the corticosteroid that is used um in part because of um
that is used um in part because of um its penetration into the CNS. So we
its penetration into the CNS. So we didn't really get into this with the
didn't really get into this with the nausea vomiting section, but
nausea vomiting section, but dexamethasone of all the cortosteroids
dexamethasone of all the cortosteroids is the most permeable into the CNS,
is the most permeable into the CNS, which is why it's used for nausea and
which is why it's used for nausea and vomiting. So you kind of get two
vomiting. So you kind of get two benefits in one with that particular
benefits in one with that particular drug. Um the other taxane that we um
drug. Um the other taxane that we um didn't cover this particular aspect was
didn't cover this particular aspect was on the slide though for dosataxel you
on the slide though for dosataxel you could get some peripheral edema due to
could get some peripheral edema due to capillary leak syndrome. So again,
capillary leak syndrome. So again, dexamethasone is recommended to try and
dexamethasone is recommended to try and block the capillary leak and
block the capillary leak and subsequently the edema. So dexamethasone
subsequently the edema. So dexamethasone is really the workhorse steroid in many
is really the workhorse steroid in many of our prophylactic regimens for
of our prophylactic regimens for multiple different indications.
multiple different indications. >> Yeah, I mean from dexamethasone is a
>> Yeah, I mean from dexamethasone is a good good drug to talk about because
good good drug to talk about because it's not only it's a
it's not only it's a pharmaccoinetic and dynamic profile fits
pharmaccoinetic and dynamic profile fits oncology well. I mean it has very little
oncology well. I mean it has very little to no mineralic corticoid activity.
to no mineralic corticoid activity. >> You don't want a drug that is going to
>> You don't want a drug that is going to facilitate increases in plasma volume
facilitate increases in plasma volume and edema. So if you think of any kind
and edema. So if you think of any kind of you know tumor that's causing
of you know tumor that's causing swelling or you have some edema
swelling or you have some edema somewhere you don't want to facilitate
somewhere you don't want to facilitate more edema you want to reduce it. And so
more edema you want to reduce it. And so dexamethasone is a classic agent um that
dexamethasone is a classic agent um that is used. We use it obviously the same
is used. We use it obviously the same reason in menitis. You don't if you have
reason in menitis. You don't if you have true suspicion for bacterial menitis,
true suspicion for bacterial menitis, you don't want to increase cerebral
you don't want to increase cerebral edema further in some way. You also want
edema further in some way. You also want to penetrate the central nervous system
to penetrate the central nervous system and so um it's a very universally uh
and so um it's a very universally uh helpful drug with a lot of different
helpful drug with a lot of different mechanisms including some antiimetic
mechanisms including some antiimetic uh properties which is why it was
uh properties which is why it was included in some of the even the
included in some of the even the antiimetic regimens that we talked
antiimetic regimens that we talked about.
about. Uh Beth, was there anything that you any
Uh Beth, was there anything that you any comment you wanted about that question?
comment you wanted about that question? >> I don't use the tag thing, so we will
>> I don't use the tag thing, so we will defer to Alison.
>> All right. Um so there was a question from Connie and I let me see if I got
from Connie and I let me see if I got this right. Uh could could we emphasize
this right. Uh could could we emphasize what information is book information and
what information is book information and what is commonly used in practice?
what is commonly used in practice? Sometimes testing can get tricky if we
Sometimes testing can get tricky if we go by common treatment versus book
go by common treatment versus book knowledge. So
knowledge. So uh you know Allison brought up a very
uh you know Allison brought up a very important um point when we got into the
important um point when we got into the uh chemotherapy induced uh nausea
uh chemotherapy induced uh nausea vomiting and that there are position
vomiting and that there are position statements or protocol guidelines
statements or protocol guidelines essentially that are you know kind of
essentially that are you know kind of the standards of care that people
the standards of care that people utilize to make those decisions. And um
utilize to make those decisions. And um and we tried to pull uh summary points
and we tried to pull uh summary points from those um documents on purpose for
from those um documents on purpose for that reason. Um where you start to see
that reason. Um where you start to see the variation in practices have to do
the variation in practices have to do with potentially formulary issues,
with potentially formulary issues, geographic biases, interpretation of
geographic biases, interpretation of literature, clinical trials that are
literature, clinical trials that are going on. A number of things that go
going on. A number of things that go into it. maybe even your interpretation
into it. maybe even your interpretation and belief of certain types of data and
and belief of certain types of data and the effect based on your p patient
the effect based on your p patient population. So, it's hard. We've tried
population. So, it's hard. We've tried very hard with the rapid review to stick
very hard with the rapid review to stick with things that are not the clinical
with things that are not the clinical minutia
minutia that will never make it to the exam. a
that will never make it to the exam. a little bit like Beth was talking about
little bit like Beth was talking about the bone marrow transplant patients
the bone marrow transplant patients where there's some vague areas that may
where there's some vague areas that may still be of debate or or institution
still be of debate or or institution specific. Um like that kind of stuff
specific. Um like that kind of stuff isn't going to make it on the board. So
isn't going to make it on the board. So you do have to play the game a little
you do have to play the game a little bit and separate yourself from what you
bit and separate yourself from what you sometimes see and do every day and what
sometimes see and do every day and what you you may even experience from what
you you may even experience from what the question is trying to ask you and
the question is trying to ask you and test you on on on the boards because it
test you on on on the boards because it has to be applicable to everybody. Um
has to be applicable to everybody. Um and I agree it is a challenge to do
and I agree it is a challenge to do that. We and again the whole point of
that. We and again the whole point of the company's name high yield med
the company's name high yield med reviews is the idea is that we're trying
reviews is the idea is that we're trying to focus in on high yield concepts
to focus in on high yield concepts that yes are clinically relevant but are
that yes are clinically relevant but are also important for your boards. So we've
also important for your boards. So we've we've tried to sift through some of that
we've tried to sift through some of that knowing that some people some of our
knowing that some people some of our customers in particular on our side want
customers in particular on our side want to dig deeper some don't. So we give you
to dig deeper some don't. So we give you guys the somewhat of a balance between
guys the somewhat of a balance between the two. We try to connect the dots if
the two. We try to connect the dots if you want to dig deeper. I'm a firm
you want to dig deeper. I'm a firm believer in our model is that we try to
believer in our model is that we try to teach people to understand why something
teach people to understand why something is if you can. So like we talked about
is if you can. So like we talked about the VA vef inhibitors and basically the
the VA vef inhibitors and basically the risk of bleeding wounds and protein ura
risk of bleeding wounds and protein ura when you start to understand the
when you start to understand the mechanism the side effects make sense.
mechanism the side effects make sense. the epidermal, you know, uh, growth
the epidermal, you know, uh, growth factor receptor blockers. It makes sense
factor receptor blockers. It makes sense that you have skin involvement, GI
that you have skin involvement, GI involvement, lung involvement. You don't
involvement, lung involvement. You don't need to memorize it at that point
need to memorize it at that point because you've connected a concept
because you've connected a concept together with core knowledge. Um, so
together with core knowledge. Um, so Connie, I don't know if I've just talked
Connie, I don't know if I've just talked in circles, didn't mean to do that, but
in circles, didn't mean to do that, but I wanted to try to help you understand
I wanted to try to help you understand the the struggle that we have knowing
the the struggle that we have knowing that there are some there's more than
that there are some there's more than one way to do something, right? So, for
one way to do something, right? So, for example, Beth also mentioned you need to
example, Beth also mentioned you need to pick an antisetamonal drug. Well, which
pick an antisetamonal drug. Well, which one, right? I mean, you can pick
one, right? I mean, you can pick sephopime and you can you can pick
sephopime and you can you can pick septacazide. You could go over to
septacazide. You could go over to pipperil and tasobactam. You could go
pipperil and tasobactam. You could go over to levofluxisonin. You could go
over to levofluxisonin. You could go over to aminoglycoside. I mean where do
over to aminoglycoside. I mean where do you what you know that variation comes
you what you know that variation comes with some of the subtle differences in
with some of the subtle differences in the patient population you're dealing
the patient population you're dealing with. But there's most of the time for
with. But there's most of the time for nonBCOP in particular or nonBC IDP if it
nonBCOP in particular or nonBC IDP if it relates to infectious disease it's going
relates to infectious disease it's going to be the traditional empiric therapies.
to be the traditional empiric therapies. Um, and they're not going to probably
Um, and they're not going to probably put the other ones on there that would
put the other ones on there that would um be together where there's two exactly
um be together where there's two exactly right answers. Uh, there's always going
right answers. Uh, there's always going to be some reason that one is better
to be some reason that one is better than the other.
than the other. Uh, so someone asked the question, miss
Uh, so someone asked the question, miss the cold. So, uh, Allison, do you mind
the cold. So, uh, Allison, do you mind just saying again what you were talking
just saying again what you were talking about the alkaloids and the cold
about the alkaloids and the cold compress versus warm compressed um,
compress versus warm compressed um, differentiation?
differentiation? >> Uh, yeah. So basically, there's a number
>> Uh, yeah. So basically, there's a number of different drugs that require
of different drugs that require different antidotes, different hot or
different antidotes, different hot or cold compresses. So I certainly don't
cold compresses. So I certainly don't have them all memorized myself and
have them all memorized myself and wouldn't suggest that you do either. Um,
wouldn't suggest that you do either. Um, but I think the key was just to know
but I think the key was just to know that typically we would think of cold
that typically we would think of cold compresses. Anytime you've got an
compresses. Anytime you've got an extravisation of anything, chemotherapy
extravisation of anything, chemotherapy or otherwise, you think about vaso
or otherwise, you think about vaso constriction and that kind of thing.
constriction and that kind of thing. However, there are some drugs that you
However, there are some drugs that you would be recommended to put a warm
would be recommended to put a warm compress on to help diffuse the
compress on to help diffuse the situation and kind to get the drug out
situation and kind to get the drug out of the vicinity, lower the concentration
of the vicinity, lower the concentration immediately. Um, so the one specific
immediately. Um, so the one specific example that I gave was the vinka
example that I gave was the vinka alkaloids and we remember that if you
alkaloids and we remember that if you think of vinka flowers where the drug
think of vinka flowers where the drug comes from, sunlight is required for
comes from, sunlight is required for them to grow. So I always remember
them to grow. So I always remember sunlight, warm compress, vinkas all kind
sunlight, warm compress, vinkas all kind of go together.
of go together. >> That's awesome. There are additional
>> That's awesome. There are additional examples beyond that. That's just the
examples beyond that. That's just the one that sticks in my mind.
one that sticks in my mind. >> Yeah. No, that's actually a very helpful
>> Yeah. No, that's actually a very helpful uh way to remember that for sure. Um so
uh way to remember that for sure. Um so someone asked a question about what dose
someone asked a question about what dose of raspberry case do you usually use? Um
of raspberry case do you usually use? Um >> controversy.
>> controversy. >> Yes. So labeling indication for
>> Yes. So labeling indication for raspberry case is a weight-based dose.
raspberry case is a weight-based dose. However, there's data out there that
However, there's data out there that shows a flat dose is just as effective
shows a flat dose is just as effective um and is cheaper. So typically most
um and is cheaper. So typically most institutions will do either a 3
institutions will do either a 3 milligram flat dose or a six milligram
milligram flat dose or a six milligram flat dose. Again that's going to be
flat dose. Again that's going to be pretty institution specific. Um we
pretty institution specific. Um we personally have a policy and it kind of
personally have a policy and it kind of says you know if it's a candidate for
says you know if it's a candidate for asb case do three unless xyz and then in
asb case do three unless xyz and then in those cases maybe consider the six
those cases maybe consider the six milligram dose. So
milligram dose. So >> I don't think that's a super clear
>> I don't think that's a super clear answer. So, I wouldn't worry about it
answer. So, I wouldn't worry about it for your test, but
for your test, but >> yeah, it's a great answer in the
>> yeah, it's a great answer in the clinical realm. Absolutely. So,
clinical realm. Absolutely. So, basically what you're saying, uh, Beth,
basically what you're saying, uh, Beth, is that that probably isn't going to be
is that that probably isn't going to be a test question even for BCOP, right?
a test question even for BCOP, right? >> I don't think so because it's
>> I don't think so because it's controversial as to whether you do the
controversial as to whether you do the labeled indication or flat dosing. And
labeled indication or flat dosing. And even flat dosing, there's two different
even flat dosing, there's two different options. So I think knowing whether
options. So I think knowing whether raspberry case is ind indicated or not
raspberry case is ind indicated or not is more important than knowing what
is more important than knowing what specific dose you would give in this
specific dose you would give in this case.
case. >> All right. So the last question that's
>> All right. So the last question that's been uh sent to us is uh what you know
been uh sent to us is uh what you know how important is it to know the the
how important is it to know the the recommendation of NCCN versus ASCO and
recommendation of NCCN versus ASCO and do we need to know the nuances?
do we need to know the nuances? >> Absolutely not. Um they're very similar.
>> Absolutely not. Um they're very similar. They're not exact. Um, but again, if
They're not exact. Um, but again, if anytime there's a gray area that can't
anytime there's a gray area that can't be on the board exam, it's going to be
be on the board exam, it's going to be something black and white. Generally,
something black and white. Generally, this is the accepted answer. Not they're
this is the accepted answer. Not they're not going to ask ASCO recommends what
not going to ask ASCO recommends what anti-imetic regimen wouldn't happen.
anti-imetic regimen wouldn't happen. >> So, just generally the principles that
>> So, just generally the principles that we talked about with multiple different
we talked about with multiple different mechanisms of action, stick with that
mechanisms of action, stick with that and don't worry so much about what one
and don't worry so much about what one says versus the other. And those of you
says versus the other. And those of you that are not on, you know, BCOP, if you
that are not on, you know, BCOP, if you just think about guidelines in general
just think about guidelines in general where there's more than one,
where there's more than one, and I mean that th there when there's
and I mean that th there when there's differences, that's because there's
differences, that's because there's differences of interpretation of
differences of interpretation of literature, there's person, there's
literature, there's person, there's bias, experience, the committee, and
bias, experience, the committee, and when the committee changes, sometimes it
when the committee changes, sometimes it changes with the the new committee. And
changes with the the new committee. And so we try to be evidence-based as much
so we try to be evidence-based as much as possible I think but nothing is like
as possible I think but nothing is like a cookbook approach or a recipe that
a cookbook approach or a recipe that says this is the way it is for everybody
says this is the way it is for everybody and that's it. You know there are some
and that's it. You know there are some scenarios where that is but that's not
scenarios where that is but that's not true for most things. So when you have
true for most things. So when you have multiple guidelines the what we advise
multiple guidelines the what we advise and where we found the most success
and where we found the most success people being is look at what's similar
people being is look at what's similar between the two. What is the concept
between the two. What is the concept that they're both advocating because if
that they're both advocating because if they're both in agreement they're
they're both in agreement they're experts.
experts. They are the people out there either
They are the people out there either doing the research or guiding the
doing the research or guiding the decisions. So if there's consistency in
decisions. So if there's consistency in a theme of what's recommended or an
a theme of what's recommended or an approach to management and or the level
approach to management and or the level of a recommendation is consistent, then
of a recommendation is consistent, then that's probably a higher yield core
that's probably a higher yield core concept that you must know. If you start
concept that you must know. If you start finding yourself again going down into
finding yourself again going down into the class 2, 2B, 2A or you know expert
the class 2, 2B, 2A or you know expert opin I mean that's not board exam
opin I mean that's not board exam material clinically relevant clinically
material clinically relevant clinically important to talk about. Sure. Because
important to talk about. Sure. Because guidelines are guides are right. They're
guidelines are guides are right. They're not absolutes. They're to give us some
not absolutes. They're to give us some direction as to what to do. Uh, another
direction as to what to do. Uh, another question popped up here is what um,
question popped up here is what um, uh, what dose of leramide is typically
uh, what dose of leramide is typically used? Two or four every four hours as
used? Two or four every four hours as needed?
needed? >> For leramide, we would do four
>> For leramide, we would do four milligrams with the first loose stool
milligrams with the first loose stool and then two milligrams with each
and then two milligrams with each subsequent stool. Typically, just the
subsequent stool. Typically, just the boxed dosing typically.
boxed dosing typically. >> Yeah, that's consistent the way it's
>> Yeah, that's consistent the way it's supposed to be. Um, can you please give
supposed to be. Um, can you please give a reference to understand what
a reference to understand what transmitter is released?
Uh, >> I don't know that we have a reference
>> I don't know that we have a reference off the top of our heads. Um,
off the top of our heads. Um, >> yeah, I do not off the top of my head,
>> yeah, I do not off the top of my head, but there's some very nice visuals. If
but there's some very nice visuals. If you you say say Google it, but that's
you you say say Google it, but that's why I tell students all the time, but if
why I tell students all the time, but if you Google it and look, there's really
you Google it and look, there's really nice diagrams of kind of a curve of
nice diagrams of kind of a curve of which neurotransmitter is being released
which neurotransmitter is being released at different time points. And it comes
at different time points. And it comes back again to the mechanism of the um
back again to the mechanism of the um nausea vomiting. So if you figure the
nausea vomiting. So if you figure the serotonin is typically released by the
serotonin is typically released by the uh cells within the stomach kind of that
uh cells within the stomach kind of that direct insult is releasing serotonin. So
direct insult is releasing serotonin. So that happens immediately while the drug
that happens immediately while the drug is still in high concentrations in the
is still in high concentrations in the system whereas the dopamine is more
system whereas the dopamine is more released from the brain not necessarily
released from the brain not necessarily that direct insult. So
that direct insult. So pathophysiologically it makes sense and
pathophysiologically it makes sense and there should be I'm sure a quick nice
there should be I'm sure a quick nice visual that you could Google. I just
visual that you could Google. I just don't have it in there.
don't have it in there. >> Perfect. Well, thank you guys so much
>> Perfect. Well, thank you guys so much for uh being on Allison and Beth. You
for uh being on Allison and Beth. You guys were fantastic. Uh we appreciate
guys were fantastic. Uh we appreciate you just sharing all your wisdom and
you just sharing all your wisdom and experience and the practical knowledge
experience and the practical knowledge especially for those that are taking the
especially for those that are taking the BOP but also not taking the BOP. Um so
BOP but also not taking the BOP. Um so thank you guys. Thank you guys also
thank you guys. Thank you guys also those who's attend and your efforts to
those who's attend and your efforts to continue to invest in your own
continue to invest in your own knowledge. Um, we hope you found this to
knowledge. Um, we hope you found this to be very useful and if you have, you
be very useful and if you have, you know, questions that come up or as
know, questions that come up or as you're studying again, please send those
you're studying again, please send those let those let us know what those are and
let those let us know what those are and we'll see you um at the next live uh
we'll see you um at the next live uh study Q&A session where we'll just kind
study Q&A session where we'll just kind of talk about different topics and
of talk about different topics and answer your questions as best we can. Uh
answer your questions as best we can. Uh recognizing that we don't know
recognizing that we don't know everything, but if we can answer the
everything, but if we can answer the question, we'll answer it for you to the
question, we'll answer it for you to the best of our ability and give you the
best of our ability and give you the right direction uh based on our
right direction uh based on our experience. So, have a good evening. Uh,
experience. So, have a good evening. Uh, thanks again for everybody's uh,
thanks again for everybody's uh, involvement. Take care. Bye-bye.
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