Download Chapter 5 Drugs for Neoplastic Disorders

5
Drugs for Neoplastic Disorders and
Immunosuppressives
Student Handout
Technician Objectives
On completing this section, the student will be
able to
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explain the importance of clear and accurate
directions on prescriptions for neoplastic
disorders.
list some special dietary and fluid
requirements associated with cancer
chemotherapy.
demonstrate the proper application of 5-FU
topical preparations.
describe the effect on the dose of Imuran if
allopurinol is added to the drug regimen.
explain the importance of compliance with
drugs that need to be taken with
chemotherapy drugs.
discuss OTC products that could have drug
interactions with prescriptions and the
important role technicians have in
identifying problem OTC purchases.
describe the different functions of
glucocorticoids and mineralocorticoids and
list drugs in each category.
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Technician Pre-Lab Questions
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In a community pharmacy, how should the
label be typed for the following prescription:
Megace suspension Sig: 800 mg QD?
A patient takes 1 tablespoon of Megace
suspension daily. How many milligrams of
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active ingredient is she taking on a daily
basis?
How does Megace suspension differ from
Megace ES suspension?
If a physician prescribes 5-FU cream to be
used on the skin, which product would you
use?
What is the equipotent dose of
dexamethasone PO to prednisone 20 mg
PO?
If a physician wanted to switch a patient
from 10 mg/day of prednisone to
methylprednisolone, what would the dose be
for the methylprednisolone?
How many milligrams of active drug are
contained in each tablet of methotrexate?
A prescription is written for MTX 7.5 mg
PO weekly. How should the directions read?
Explain the directions for the administration
of nystatin suspension for the treatment of
oral candidiasis (thrush).
How many milligrams of active drug are in
each Eulexin capsule?
What is the advantage of Casodex over
Eulexin?
A patient is taking four Imuran 50-mg
tablets daily. The physician adds a new
product, Zyloprim, 300 mg once daily. What
should be the new dose of Imuran?
A person taking Premarin is given a new
prescription for Nolvadex. What is the
outcome if they are taken concurrently?
Why would folic acid not be appropriate for
use as a “leucovorin rescue” therapy with
high-dose MTX therapy?
A patient takes PO Cytoxan. What adverse
effect does the patient risk experiencing?
How much water should the patient drink
each day to minimize the risk of the adverse
effect?
Instructor's Answer Key for Chapter 5
because of a drug interaction that affects
metabolism.
Technician Objectives
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Explain the importance of clear and accurate
directions on prescriptions for neoplastic
disorders.
Neoplastic drug therapy can be very
complicated and potent. Inaccurate
directions can cause serious harm to the
patient and, in some cases, death. The
pharmacist should counsel the patient about
proper usage, but it is vitally important that
the directions on the prescription be exact.
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A patient taking Flutamide and Lupron
should be sure they are taken together at the
proper intervals. Often a glucocorticoid is
prescribed for a patient using Efudex Cream
to reduce inflammation.
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List some special dietary and fluid
requirements associated with cancer
chemotherapy.
Demonstrate the proper application of 5-FU
topical preparations.
5-FU topical preparations should be applied
twice daily in an amount sufficient to cover
lesions. Carac brand of 5-FU is applied once
a day. Avoid unaffected areas of the skin
and the eyes, nose, and mouth. If applied
with fingers, the hands should be washed
thoroughly. Treatment should continue until
the inflammatory response reaches erosion
(15 days), necrosis, and ulceration stages,
which might require 2 to 6 weeks.
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Describe the effect on the dose of Imuran if
allopurinol is added to the drug regimen.
The dose of Imuran needs to be reduced to
one-quarter to one-third of the original dose
if allopurinol is added to the drug regimen
Discuss OTC products that could have drug
interactions with prescriptions and the
important role technicians have in
identifying problem OTC purchases.
The technician is often in a position to
prevent many potentially serious
complications from inappropriate OTC drug
use. Often the patient will bring an OTC
product to the counter when picking up
prescriptions, and the technician can alert
the pharmacist to the need for counseling.
Aspirin is contraindicated with many
chemotherapy drugs because of the risk for
bleeding.
Most, if not all, chemotherapy agents require
adequate fluid intake (e.g., Cytoxan requires
2 to 3 L/day) to help with transport and
elimination from the system. Many of these
drugs should be taken with food to lessen
nausea. Alcohol is contraindicated in most
chemotherapy.
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Explain the importance of compliance with
drugs that need to be taken with
chemotherapy drugs.
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Describe the different functions of
glucocorticoids and mineralocorticoids and
list drugs in each category.
Glucocorticoids aid in the metabolism of
carbohydrates, proteins, and fats. They
suppress inflammatory responses in the
body and help maintain a normal blood
pressure.
Mineralocorticoids aid in the regulation of
electrolytes by controlling the reabsorption
of sodium and the secretion of potassium by
the kidney tubules. Examples of
glucocorticoids are cortisone,
hydrocortisone, prednisolone,
methylprednisolone, and dexamethasone.
Examples of mineralocorticoids are
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desoxycorticosterone acetate and pivalate
and fludrocortisone acetate.
8 mg.
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How many milligrams of active drug are
contained in each tablet of methotrexate?
Technician Pre-Lab Questions
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In a community pharmacy, how should the
label be typed for the following prescription:
Megace suspension Sig: 800 mg QD?
2.5 mg is most common. Also available in 5,
7.5 and 10 mg.
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Megace suspension 40 mg/mL. Take 4
teaspoonfuls each day.
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If a physician prescribes 5-FU cream to be
used on the skin, which product would you
use?
5-FU cream is available as a 1%
(Fluoroplex) and as a 5% (Efudex). If the
strength or a brand name is not specified, the
physician should be called to verify the
strength.
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How does Megace suspension differ from
Megace ES suspension?
Megace suspension has a concentration of
40 mg/mL and is available in 240-mL
bottles; Megace ES suspension has a
concentration of 125 mg/mL and is supplied
as a 150-mL bottle.
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It could be taken as three tablets of 2.5 mg at
one time with a large glass of water.
Alternatively it could be 7.5 mg (3 tablets)
each week on the same day with a 12-hour
interval between doses, so it could be 2
tablets at 11 a.m. and 1 tablet at 11 p.m.
A patient takes 1 tablespoonful of Megace
suspension daily. How many milligrams of
active ingredient is she taking on a daily
basis?
1 tablespoonful =15 mL; 15 mL × 40
mg/mL = 600 mg
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How many milligrams of active drug are in
each Eulexin capsule?
125 mg
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What is the advantage of Casodex over
Eulexin?
Casodex can be dosed only once a day as
opposed to three times a day for Eulexin.
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What is the equipotent dose of
dexamethasone PO to prednisone 20 mg
PO?
If a physician wanted to switch a patient
from 10 mg/day of prednisone to
methylprednisolone, what would the dose be
for the methylprednisolone?
Explain the directions for the administration
of nystatin suspension for the treatment of
oral candidiasis (thrush).
Shake the suspension and place the dose in
the buccal cavities of the mouth. Swish the
suspension and hold in the mouth for a few
minutes before either swallowing or spitting
as the directions indicate.
3 mg of dexamethasone is equivalent to 20
mg of prednisone.
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A prescription is written for MTX 7.5 mg
PO weekly. How should the directions read?
A patient is taking four Imuran
(azathioprine) 50-mg tablets daily. The
physician adds a new product, Zyloprim
(allopurinol) 300 mg once daily to treat high
uric acid. What should be the new dose of
Imuran?
The Imuran dose should be reduced by
three-quarters. 50 mg/day is correct.
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A person taking Premarin is given a new
prescription for Nolvadex. What is the
outcome if they are taken concurrently?
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Premarin is an estrogen, and Nolvadex is an
antiestrogen. They will cancel out each
other.
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Why would folic acid not be appropriate for
use as a “leucovorin rescue” therapy with
high-dose MTX therapy?
Leucovorin is an active metabolite of folic
acid that can be used as a rescue therapy.
Methotrexate is a folic acid antagonist, and
folic acid would not be active against it.
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A patient takes PO Cytoxan. What adverse
effect does the patient risk experiencing?
How much water should the patient drink
each day to minimize the risk of the adverse
effect?
The patient is at risk for hemorrhagic cystitis
and should drink 2 to 3 L of water per day.
Prescription Practice
Suggested technician answers for the
Prescription Practice exercises are given below.
The medication orders for each prescription are
deciphered and reprinted in italics, followed by
the information the pharmacy technician should
be aware of when filling the prescription for the
patient.
The student is responsible for interpreting
common pharmacy abbreviations (Sig codes),
such as “1 po bid,” which are not translated
below. If these abbreviations are entered in a
software program, the computer will translate
and print on the label (e.g., "Take one tablet by
mouth two times a day").
5.1 Cynthia Smith
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Prednisone 5 mg: Take 1 tablet daily
after breakfast
Inflamase Forte 1% 10 cc: Place 1 drop
in right eye bid
Have the pharmacist call the physician
to be sure prednisone is 5 mg, not 50
mg.
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Also ask the physician how many
tablets to dispense.
The pharmacist will demonstrate the
application of drops.
The patient should wash his or her
hands before and after administration.
Auxiliary label on prednisone: Take
with food.
Auxiliary label on Inflamase Forte: For
the eye.
5.2 Michael Murphy
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Flutamide 125 mg #100: Take 2 po tid
Tylenol/Codeine elixir 1 pint: Take
20 cc po q4h prn
If Dr. Griffin’s DEA number is not in
the computer records, call the office to
record it on the prescription.
The pharmacist will counsel the patient
to drink plenty of water with liquid
codeine and avoid alcohol. Also warn
about drowsiness.
Auxiliary labels on Tylenol/Codeine:
No alcohol. May cause drowsiness.
Federal law prohibits transfer.
5.3 Diane Myers
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Tamoxifen 10 mg #180: Take 1 po bid
Paxil 20 mg #30: Take ½ tablet qhs for
4 days then 1 qhs thereafter.
The pharmacist will counsel the patient
on the importance of compliance with
tamoxifen and need to take it with food
to prevent gastrointestinal (GI) upset.
Paxil will take several weeks to begin
working and may cause constipation; a
fiber laxative will help with this.
5.4 Patricia Anderson
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Tamoxifen 10 mg #100: Take 1 po bid
Avapro 150 mg #30: Take 1 po qd
Be sure to enter the two physicians
correctly.
Tamoxifen will bring up a drug
interaction on the computer; have the
pharmacist call the physician. Premarin
is an estrogen, and tamoxifen is an
antiestrogen, so they will cancel out
each other. Premarin should be DC’d.
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Chapter 5
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5.5 John Johnson
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Efudex 5% cream 25 grams: Apply bid
for 2 weeks and see me (the prescriber)
Triamcinolone Acetonide 0.5% HP
cream 15 grams: Apply bid
Triamcinolone is a glucocorticoid to
help with inflammation caused by
Efudex.
The pharmacist should counsel the
patient on application procedure and
need to wash the hands thoroughly to
avoid systemic absorption.
The patient must use sunscreen with
SPF greater than 30, avoid sun, and
wear a hat when in the sun.
The pharmacist will inform the patient
about burning and redness that will
begin in 6 days and get worse until day
14. These effects are part of therapy,
but if pain is severe, the patient should
contact his physician.
Auxiliary label on both: External use.
Auxiliary label on Efudex: Avoid sun.
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5.8 Benjamin Meyer
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5.6 Mary Schmidt
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Megace 1 pint (200 mg/5 cc): Take 20
mL BID
HCTZ 25 mg #30: Take 1 po qd
The pharmacist will counsel the patient
about the need to increase caloric intake
because Megace will only help with
appetite. Might add Ensure Plus.
Be sure to enter the two physicians
correctly.
5.7 Lester Kelly
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Imuran 50 mg # 50: Take 1 po bid
Indocin 25 mg #15: Take 1 po tid for 5
days
The computer will alert to drug
interaction with Zyloprim in the profile
and Imuran.
The pharmacist will call both physicians
to alert them. Zyloprim will inhibit
metabolism of Imuran and allow toxic
buildup. Imuran dose should be reduced
to one-quarter to one-third of the
original dose. (From 100 mg to 25 mg
/day)
Auxiliary label for Indocin: Take with
food or milk. Avoid aspirin.
The patient should be advised to consult
the pharmacist before choosing
additional OTC analgesics.
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Verapamil 80 mg po tid
Dyazide one qd
Digoxin 0.125 mg qd
Pepcid 40 mg hs
Prednisone 5 mg bid
Cipro 750 mg #10: Take 1 po bid
Call the physician for quantities of each
drug.
Duplicate therapy interaction with
Lanoxin in the patient profile. The
physician needs to be contacted to see if
the dose has been reduced and if a
generic is allowed because the patient
has been taking the brand name
Lanoxin.
The pharmacist will also counsel the
patient about taking prednisone with
food to protect the stomach.
Verapamil has a strong tendency to
cause constipation, so the pharmacist
will recommend high-fiber foods and
possibly a fiber laxative.
Auxiliary labels on verapamil and
prednisone: Take with food. Auxiliary
labels on Cipro: Avoid sun exposure.
Take all of this medication until gone.
Do not take with milk or antacids.
5.9 Lyndon Peterson
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Folic Acid 1 mg #100: Take 1 po bid
Efudex Cream 5% g: Apply to nose bid
The strength 1.0 mg could be misread
as 10 mg. The zero behind the decimal
point should be omitted.
Note the two different prescribers and
enter them correctly.
The pharmacist will counsel the patient
on proper application of Efudex,
particularly the need to wash the hands
thoroughly and avoid contact with the
eyes.
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The patient must wear sunscreen SPF
30 or more, wear hats and avoid sun.
Auxiliary labels on Efudex: Avoid sun.
For external use only.
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5.10 Susan Williams
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Folic acid 1 mg: Take one tablet each
day
Nystatin suspension 240 Ml: Swish and
swallow 6 mL qid for 10 days
Be sure folic acid is not dispensed. If in
doubt, call the physician.
Although nystatin suspension is usually
swallowed, the abbreviation “S&S”
sometimes means “swish and spit.” The
prescriber should be contacted to make
certain of the directions.
The patient should be reminded to
distribute the nystatin around her whole
mouth and retain it as long as possible
(at least 5 minutes).
Note the two different prescribers and
enter them correctly.
Call the refill history to pharmacist’s
attention. If taken as directed (1 qd), the
Amaryl would have been due for refill
on 8/6. Sometimes fungal infections
result from poor glycemic control.
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5.13 Mary Sullivan
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Methotrexate 2.5 mg #16: Take as
directed
Zantac 300 mg #30: Take 1 qhs
The pharmacist should ascertain from
the patient exactly how methotrexate is
to be taken.
The dose should be once a week, either
at one time or at 12-hour intervals.
Mistaken daily use of this drug has led
to fatal toxicity.
Avoid aspirin and NSAIDs.
Note the different prescribers on two
prescriptions.
Auxiliary label on methotrexate: Avoid
sun.
5.12 William Hoffman
Prednisone 10 mg #50: Take 3 po q am
for 3 days, then 2 po q am for 3 days,
then 1 po daily for 3 days
Prilosec 20 mg #25: Take 1 po q am
before breakfast
Auxiliary label for prednisone: Take
with food or milk to protect stomach.
For Prilosec: Take on empty stomach
30 minutes before breakfast.
5.14 George Smith
5.11 Lisa Cooper
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Methotrexate 2.5 mg #12: Take 3 tabs
po q week (Tues)
Folic acid 1 mg #100: Take 2 po qd
The pharmacist will counsel the patient
about taking methotrexate all at once
every Tuesday, or at 12-hour intervals
between doses, the need to follow
instructions exactly, and the need to
take the drug with plenty of water.
The pharmacist will explain to the
patient that folic acid is to be taken on
the days when methotrexate is not
taken.
Auxiliary label on methotrexate: Avoid
sun. Take with full glass of water.
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Prednisone 5 mg #100: Take 3 tabs po
bid
Zantac 150 mg #60: Take 1 po with
breakfast and at bedtime
The computer will bring up a duplicate
therapy interaction with the prednisone
in the patient profile. It is prescribed by
a different physician, so both physicians
should be called. While speaking with
the physician, verify that the 30-mg
dose of prednisone daily should be
continued for all the refills; the
physician may want to taper down the
dose.
The pharmacist will then counsel the
patient on the prescriber’s instructions
and to take with food to prevent GI
upset.
Auxiliary label: Take with food.
5.15 Sean Nelson
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Prednisone 1 mg tablets #18: Take 4
tabs po qd for 2 days then 3 po qd
Efudex Cr 1% 25 grams: Apply every
week carefully to left lower eyelid and
upper cheek Avoid eye
Note different physicians.
Prednisone directions are unclear; have
the pharmacist call the physician to
verify because tablet amount does not
come out even.
Efudex prescription contains an error:
Efudex is 5%; Fluoroplex is 1%. Call
the physician to clear this up because
dispensing 5% Efudex if 1% is
prescribed can cause serious skin
irritation.
With either product, the patient should
wear sunscreen with SPF 30 or higher
and avoid sun exposure.
Auxiliary labels on Efudex: External
use. Avoid sun.
Auxiliary label on prednisone: Take
with food.
5.16 Fred Brown
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Casodex 50 mg #120: Take 1 po qd
Celebrex 200 mg #30: Take 1 po qd
The pharmacist should remind the
patient to see the physician for Lupron
injections.
The patient should be reminded to avoid
aspirin and other OTC analgesics.
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5.19 Melinda Granox
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Megace 240 cc: Take 10 cc hs
Neurontin 200 mg #20: Take 1 po at
bedtime
The pharmacist will counsel the patient
on adding extra calories to his diet.
Auxiliary label for Megace: Shake well.
For Neurontin: May cause drowsiness;
Avoid alcoholic beverages. Exercise
caution while driving or operating
machinery.
5.18 Harry Morris
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Imuran 50 mg #100: Take three po qd
Tylenol #3 #60: Take 2 q4h prn
Arimidex 1 mg #30: Take 1 po qd
Zantac 150 mg #50: Take 1 po qd
Call propranolol refill history to
pharmacist’s attention; if the dose has
not changed, then the most recent refill
is 30 days early.
5.20 Mario Ariola
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Prednisone 20 mg #150: 3 po qd
Cytoxan 50 mg #60: 2 po qd
Compazine tablets 10 mg #30: 1 po qid
Folic acid 1 mg #30: 1 po qd
Macrobid #10: 1 po bid after meals
Auxiliary labels for Macrobid: Avoid
antacids. Drink plenty of fluids.
5.21 Mary Reiland
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5.17 David Wagner
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The patient should receive medication
guide warning about reporting unusual
bleeding, sore throat, and so on.
Auxiliary label for Tylenol #3: Federal
law prohibits transfer.
The pharmacist should counsel the
patient about avoiding acetaminophencontaining OTC products.
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Efudex cream 5% small tube: Apply to
lesion bid
Toprol XL 50 mg #30: Take 1 po qd
The pharmacist will be sure patient
knows the location of the lesion to
which Efudex is to be applied.
Auxiliary labels for Efudex: Avoid sun
exposure. External use only. Use until
gone.
5.22 Martha Hausser
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Methotrexate 2.5 mg #40: Take 10
tablets po weekly.(On one day)
Oxycontin 20 mg #21: Take 1 po tid
The physician’s DEA number is
required for OxyContin prescription
Note the instruction to dispense in a
container without a childproof cap.
Usually, the patient is required to sign a
release acknowledging this packaging.
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Pharm Tech Instructor's Guide
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The pharmacist will discuss the best
way to take 10 methotrexate tablets per
week—either all in one day or in three
doses (q 12h) over a 2-day period.
Auxiliary labels for methotrexate:
Avoid sun. Drink plenty of fluids.
Auxiliary labels for OxyContin: Avoid
alcohol. Take with food or milk.
Federal law prohibits transfer.
Patient Care Management: A Lab Workbook for Prescription Practice, 3rd ed
Pharm Tech Instructor's Guide
Chapter 5
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