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214 Cards in this Set

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List 3 drugs that may exacerbate Asthma
***BAN

Beta Blockers
Aspirin
NSAID's
How do you get a patient's Peak Expiratory Flow?
Patient has to stand up straight, hold peak flow meter horizontally, and blow into the meter. Repeat 2x and RECORD THE HIGHEST OF THREE READINGS.
What should be done if an Asthma Px is at Red Zone?
Take up to 3 treatments of 4-6 puffs of beta2-agonist every 20 min.
Take oral steroids (40-60mg, 3-10days)
Go to ER or call 911
What should be done if an Asthma Px is at Yellow Zone?
2-4 puffs of Beta2-agonist Q20 min x 3 doses.
After 1 hr:
If at green: beta agonist & inhaled steroid for 7-10 days
If at yellow: beta agonist & oral steroid
What are the other names for Beclomethasone?
QVAR
Vancenase/Beconase (nasal)
Vancenase AQ/Beconase AQ (double strength nasal)
What's the age range for QVAR?
5-11 yo: 40mcg, 1-2 puffs BID
Adults: 80mcg, 1-2 puffs BID
What are the different brands names for Budesonide?
Pulmicort (Turbuhaler & Flexhaler) - DPI
Rhinocort (allergic rhinitis)
Entocort EC (caps for Crohn's)
What is the difference between Pulmicort Turbuhaler and Flexhaler?
Flexhaler has a dose counter
What is Entocort EC?
Budesonide capsules used for Crohn's.
List the lactose-containing inhalers (4)
Flexhaler (Pulmicort)
Asmanex
Foradil
Advair Diskus
What are the other names for Flunisolide?
AeroBid
AeroBid-M (with menthol)
Aerospan - comes with a spacer
What is the strength and how is Medrol Dose Pack given?
Methylprednisolone = 4mg

Dose: taper over 6 days (21 tabs total)
What are the medications used to prevent premature delivery?
Terbutaline

Alternatives: MgSO4, Indomethacin, Makena (NEW!!!!)
What are the different brands for Mometasone?
Asmanex: for >12 yo
Nasonex: nasal
Elocon: topical
What are the brands for Fluticasone?
Flonase

Veramyst - has fluticasone furoate instead of fluticasone propionate

Flovent (MDI & DPI)
What is Alvesco? Dosing?
Ciclesonide, for >12 yo BID
What is Omnaris?
Ciclesonide for allergic rhinitis
What is Intal? Dosing?
Cromolyn, for >2 yo, 2 puffs QID
What is Tilade? Dosing?
Neodocromil, for >6 yo, 2 puffs QID
What the Long Acting Beta2-Agonists (LABA)?
Salmeterol (Servent)
Formoterol (Foradil)
What is Servent? How long is it good for after opening?
Salmeterol; good for 6 weeks after opening foil
Dosing for Servent?
For >4 yo, 2 puffs BID or 30-60 min prior to exercise
Advair is good for how long after opening the foil?
1 month; for >4 yo
Foradil dosing?
BID or 1 puffs 10 min prior to exercise.
For >5 yo
What is Symbicort? Good for how long? Age range?
Formoterol with Budesonide; good for 90 days after opening; for >12 yo
Brand names for Theophylline?
Elixophyllin
Theo-24
Uniphyl
Aminophylline quivalence of oral to IV theophylline?
IV aminophylline = 85% of theo
PO aminophylline = 80% of theo
What is the max dose for Theophylline?
900mg/day
What is the target serum concentration of Theophylline?
5 - 15 mcg/mL
SE of theophylline?
>15mcg/mL - toxicity
>30mcg/mL - SVT
>50mcg/mL - seizure
What are the Anti-Leukotrienes used for Asthma?
Montelukast (Singulair) - QHS

Zafirlukast (Accolate) - BID, empty stomach

Zileuton (Zyflo) - BID
What is the dosing for Singulair?
10 mg QHS > 15 yo
5 mg QHS : 6-14 yo
4 mg QHS : 2-5 yo
Can you use Singulair to prevent exercise induced bronchospasm?
Yes; must be taken 2 hours prior to activity
What do you need to check with Zyflo?
LFT's
Zyflo can increase concentration of what medications?
Theophylline and Warfarin
What is Omalizumab? Dose?
Xolair (Omalizumab) is for >12 yo, 150-375mg SQ Q2-4 weeks
What is the blackbox warning for Xolair?
Anaphylaxis
Xopenex is good for how long after opening?
Open the foil, 2 weeks.
Open the vial, 1 week.
What is Atrovent? Dose?
Ipratropium; 2-3 puffs QID
Atrovent is contraindicated in what allergy?
Soy and peanut allergy
What are the 2 brands for Ipratropium-Albuterol combination?
Combivent - inhaler
Douneb - nebulizer
What is Tiotropium? Advantage over Atrovent?
Spiriva; once a day dosing compared to Atrovent which is QID
What is Brovana?
Aformoterol; an LABA nebulizer sol'n.
What is Performist? Storage?
Formoterol, an LABA nebulizer sol'n.; Fridge
What are the Dry Powder Inhalers?
Flexhaler (Pulmicort/Budesonide)
Advair
Spiriva
Foradil
Flovent diskus
Asmanex
Serevent diskus
Patient has hyperglycemia if fasting glucose is what? Post-prandial glucose of what?
FG >126 mg/dL
Post Prandial Glucose >200
A pregnant patient has hyperglycemia if FG is what?
FG >105
What are the two Diabetes meds for pregnant women?
Glyburide (Micronase, Diabeta)
Metformin (Glucophage)
What are the 3 short acting insulins?
Lispro - Humalog
Aspart - Novolog
Glulisine - Apidra
What is Detemir? How long outside the fridge?
Levemir
Good for 42 days outside the fridge.
What is Glargine? How long out of the fridge?
Lantus; good for 28 days out of the fridge.
What routes of injection can you give regular insulin?
IM, IV, SC
What routes of injection can you give Apidra?
IV and SQ
What is the insulin dosing for Type I & II Diabetes?
Type I: 0.5 - 0.8U/kg
Type II: 0.7 - 1.5U/kg
What is Symlin? Dosing? #1 SE?
Pramlinitide (Symlin)

Type I: 15U TID AC
Type II: 60U TID AC

SE: Nausea
Don't give Symlin to patients with?
A1C > 9%
Hypersensitivity to metacresol
GI motility meds
Alpha glucosidase inhibitors
What are some of the symptoms for Diabetic Ketoacidosis?
***FAN

Fruity breat
Abdominal pain
N/V
What is the DoC for renal patients with DM? Dose?
Glipizide, 30 min AC
Max: 20mg BID
What are the other names for Glyburide? Max?
Diabeta & Micronase, max: 10mg BID
Glynase (micronized), max: 12mg
What is Amaryl? Max?
Glimepiride
Max: 8mg
What are the other names for Metformin? Max dose?
Glucophage, 2550mg
Glucophage ER & Glumetza, 2000mg
Fortamet ER, 2500mg
what is Glucovance?
Glyburide-Metformin
What is Avandamet?
Rosiglitazone-Metformin
What is Prandimet?
Repaglinide-Metformin
Caution/contraindication for the use of Metformin
Males: SCr>1.5
Females: SCr>1.4
Liver disease, COPD, CHF
MoA of Thiazolidinediones? SE?
MoA: insulin sensitizers (Pioglitazone, Rosiglitazone)

SE: ***DALE

Decrease bone density
Avoid in CHF patients
Liver disease
Edema
Patient has LFT's of >2.5x normal. Is it okay to give a thiazolidinedione?
DO NOT start medication if LFT's are >2.5x normal
What is Glyset?
Miglitol, alpha-glucosidase inh
What is Precose? Dose?
Acarbose, 100mg TID with food
If patient is <50kg, 50mg TID max.
What is Repaglinide? Dose?
Prandin (Repaglinide)

Max: 16mg, 15 min AC
What is Starlix? Dose?
Nateglinide (Starlix)

Max: 60-120mg, 30 minutes AC
What is Sitagliptin? Dosing?
Januvia (Sitagliptin)

-CrCl>50mL/min: 100mg QD
-CrCl 30-49mL/min: 50mg QD
-CrCl <30mL/min: 25mg QD
What is Saxagliptin? Dose?
Onglyza (Saxagliptin)

Max: 2.5mg for renal pts or if taken with inhibitors.
SE for Gliptins?
Pancreatitis
Abdominal pain, N/V
HA (headache)
Upper respiratory tract infection
What is Byetta? Dose?
Exenatide (Byetta)

Dose: 5-10mcg SC BID 60 min before meals (6 hours apart)
Can you use Byetta if patient has CrCl <30? Storage?
No.

Storage: Fridge or 30 days RT
Black box warning for Byetta?
Pancreatitis and Renal failure
What is Victoza? Dosing?
Lariglutide (Victoza)

Dose: 6mg SC daily >18 yo
Black box warning for Victoza?
thyroid tumors
List meds that can cause Osteoporosis
Steroids
Anti-epileptic
Aromatase inhibitors
Gonadotropin RH
What is Evista? Indications?
Raloxifene (Evista)
Breast Cancer & Osteoporosis
What is Aredia? Dose?
Pamidronate
30-90mg IV infusion over 2-24H
What is Alendronate?
Fosamax
What is Risedronate?
Actonel

Atelvia DR - can be taken WITH FOOD
What is Ibandronate? Strengths?
Boniva, 2.5 & 150mg tabs
What are the other names for Zolindronic Acid?
Reclast, a yearly IV infusion
Zometa, 4mg IV infusion Q3-4W
What is Zometa?
Zolindronic Acid, 4mg given in a 15 minute IV infusion

Indications: bone metastases/tumors, hypercalcemia, multiple myeloma
What are the names for Calcitonin? Storage?
Miacalcin - inj & nasal spray, 35 days RT
Fortical - nasal spray, 30 days RT
What is the dose for Miacalcin injection?
100U SC/IM daily
How many days can Fortical be out of the fridge?
30 days
Calcitonin is contraindicated in what allergy?
Salmon allergy
What is Forteo? Dose? Storage?
Teriparatide (Forteo)

Dose: 20mcg SC QD

Storage: 28 days even if pen is not empty
Other names for Estradiol (patch)? Frequency of dosing?
Menostar - 1 patch QW
Alora - 1 patch 2x QW
Climara - 1 patch QW
Combipatch - 1 patch 2x QW
Vivelle Dot - apply twice a week
What is Rheumatrex? Max dose?
Methotrexate
Max: 20mg QW
What is the antidote for Methotrexate toxicity?
Leucovorin (folinic acid)
What do you monitor at baseline when giving Methotrexate?
CBC
Chest X-ray
LFT
Renal fxn
Methotrexate adverse effects?
Mucocytosis
Pulmonary fibrosis
Hepatotoxicity
Renal toxicity
Myelosuppression
Absolute contraindications for the use of Methotrexate?
Pregnant & lactating women
SCr >1.5
Diarrhea or any infection
Immuno-deficiency
What is Arava? Dose?
Leflunomide
LD: 100mg PO QD x 3
MD: 10-20mg PO QD
What is the half life of Arava? What can you use for a washout procedure?
2 weeks

Washout: Cholestyramine 8grams TID x 11 days
What is Kineret? Dose? Storage?
Anakinra, interleukin-1 receptor blocker
100mg SC QD
Fridge
Kineret SE?
Neutropenia (monitor CBC)
What is Imuran?
Azathioprine
Imuran converts into what?
6-mercapto purine, which lowers the immune system
Cuprimine dosing?
Month 1: 250mg
Month 2: 500mg
Month 3: 750mg
Month 4: 1000mg
Titrate slowly!!!!!! EMPTY STOMACH!!!!
What is Hydroxychloroquine? Dose? SE?
Plaquenil (Hydroxychloroquine) is given 200mg BID.

SE: CNS effects and Retinopathy
What is Azulfidine? Dose?
Sulfasalazine
500mg QD-BID after meals
What allergy is Azulfidine contraindicated?
Sulfa
Salicylate
What is Enbrel? Dose? Storage?
Etanercept (Enbrel) is a TNF blocker

Dose: 50mcg SQ weekly

Storage: Fridge
What is Remicade?
Infliximab (Remecade)

Dose: IV infusion 6x/year
What is Humira? Dose?
Adalimumab (Humira)

Dose: 40mg Q2W on the front of the thighs or abdomen area
What is Golimumab? Dose?
Simponi (Golimumab)

Dose: 50mg SC Qmonth
What is the black box warning for Simponi?
Risk of TB invasive fungal infection
What is Cimzia?
Certolizumab
SQ 1-2x Qmonth
What is Orencia? How is it given?
Abatacept

IV infusion Qmonth
Orencia dosing?
<60kg 50mg
60 - 100kg 750
>100kg 1 gram
What is Rituxan? Dose?
Rituximab
1 gram IV Q2 weeks (2 doses total)
What do you premedicate with before using Rituxan?
Methylprednisolone, 100mg IV 30 minutes prior to infusion to prevent severe infusion reactions.
What is Aloxi? Half-life? Dose?
Palodosetron
Longest half-life (36 to 48H)
Dose: 0.5mg 1H prior to chemo
What is Dolasetron? Forms?
Anzemet comes in IV/PO
What is Zofran? Forms?
Ondansetron
IV/IM/PO/ODT
What is Granisetron?
Kytril/
Sancuso (patch) - can be worn up to 7 days
Are steroids good for N/V by themselves?
Yes, but also good when used with 5HT3 or Reglan
What is Decadron?
Dexamethasone
What is the prophylactic dose for Decadron?
8mg IV or 12mg PO prior to chemo
8mg PO QD for 2-4 days
Treatment dose when using Decadron for N/V?
Dexamethasone (Decadron)

Dose: 10-20mg IV/PO Q4-6H
What is Cesamet? What schedule does it belong?
Nabilone
Schedule II
What is Marinol? What schedule does it belong?
Dronabinol
Schedule III
What is the frequency of dosing for Marinol? Storage?
TID
Fridge
What is the dosing frequency of Cesamet? Storage?
BID
Room temperature
What is Emend? Dose?
Fosaprepitant
115 mg injection combined with 5HT3 blocker & steroid
What is the dosing for Aprepitant?
1st day: 125mg PO
2nd & 3rd day: 80mg
Use in combination with Decadron & Zofran
What is the indication for Erythropoietin? Dose? Brands?
Anemia
SC 3x Qweek
Procrit & Epogen
What is Aranesp? Used for? Dosing?
Darbepoietin for chemo-induced anemia
2.25mg/kg SQ every week
What is Neumega?
Oprelvekin, used for bleeding/thrombocytopenia
What do you need to monitor with Neumega?
Fluid & electrolytes
What is Filgrastim?
G-CSF, Neupogen
Used for Leukopenia (increase in infection)
Points to remember for Neupogen & Neulesta?
Bone pain
Refrigerate (Neupogen: 24H RT; Neulesta: 48H RT)
Protect from light.
Filgrastim dosing? Storage?
Filgrastim (G-CSF, Neupogen)

5mcg/kg/day
Fridge, use w/n 24H when room temp
Neulesta dosing? Dosing?
6mg SC 1x each chemo cycle
Fridge
What is the antidote for a high potassium level in the body?
Sodium polystyrene sulfonate (Kayexalate)
What is Herceptin?
Herceptin (Trastuzumab) is approved for the treatment of HER2 breast cancer in combination with Paclitaxel
What are the advantages of Aromatase Inhibitors over SERMs?
NO hypercalcemia
NO thromboembolism
NO endometrial cancer
Herceptin form? Dose?
Trastuzumab (Herceptin)

Form: IV infusion

Dose: Initial - 4mg/kg over 90 minutes, then 2mg/kg over 30 minutes for 51 weeks.
What is Tykerb? Dose?
Lapatinib (Tykerb)

Dose: 5 tabs daily x 21 days with XELODA (CAPECITABINE)
What is Zolinza? Indicated for? Dose?
Vorinostat, for lymphoma
400mg QD with food
What is Nolvadex?
Tamoxifen
Who is Tamoxifen indicated for?
Pre-menopausal women
What drugs should not be given with Tamoxifen?
Strong 2D6 inhibitors (Paxil, Prozac, Zoloft, Cymbalta, Amiodaron) bec. Nolvadex needs to be converted by CYP2D6 to its active metabolite
What is Evista?
Raloxifene
What is Anastrozole? Dose?
Arimidex (Anastrozole), 1mg QD
What is Letrozole? Dose?
Femara (Letrozole), 2.5mg QD
What is Exemestane? Dose?
Exemestane (Aromasin), 25mg QD
What is Ixabepilone? Dose?
Ixempra
40mg/m2 by IV infusion over 3 hours Q3 weeks
Tykerb dosing?
Lapatinib, 5 tabs QD x 21 days with Capecitabine (Xeloda)
What is Megestrol?
Megace
What is Zoladex?
Goserelin
What is Lupron?
Leuprolide
What is Trelstar?
Triptorelin
What is Abarelix? Indication?
Plenaxis depot, for patients who can't have LHRH agonists
What is Eulixin?
Flutamide
What is Casodex?
Biclutamide
What is Nilandrone?
Nilutamide
What is Avodart?
Dutasteride
What is Finasteride?
Proscar, 5mg
Propecia, 1mg
What do you give with Cisplatin? Why?
Amifostine (Ethyol), to protect the kidneys.
What do you give with Cyclophosphamide?
Mesna binds to acrolein, therefore works as prophylaxis against hemorrhagic cystitis
SE of Cyclophosphamide?
Hepatotoxicity
Nephrotoxic
Hemorrhagic cystitis
Agranulocytosis
Alopecia
Sterility problems
What is Cytoxan?
Cyclophosphamide
What is Myleran?
Busulfan
What are the SE of Busulfan?
Increase in Uric Acid
Pulmonary fibrosis
What is Treanda? Form?
Bendamustine, IV infusion
How do you reconstitute Treanda?
100mg in 20mL of Sterile H2O, transfer to a 500mL infusion bag of 0.9% NaCl
How long can you store Treanda?
24H if refrigerated or 3H at room temperature
Capecitabine is a pro-drug of what? Dosing?
5-Fluorouracil
2 weeks on, 1 week off (cyclical)
Take 30 min PC in the AM & PM
What is Cytostar?
Cytarabine
What is the antidote for cardiotoxicity due to Doxorubicin/Daunorubicin?
Dexrazoxane (Zinecard)
SE for Mitoxantrone?
Turns everything blue.
What do you premedicate with Docetaxel?
Decadron, 8mg BID x 3-5 days, start 1 day prior
What is Octreotide?
Sandostatin, unlabeled use for diarrhea
What are the brands for Formoterol?
Formoterol (Foradil) - DPI

Formoterol + Budesonide (Symbicort) >12 YO

Formoterol + Mometasone (Dulera) >12 YO
Asthma Management Stepwise Approach
Step 1: SABA (short acting Beta agonish) MDI PRN

Step 2: Low dose ICS
Alt: Cromolyn or Leukotriene Inh

Step 3: Low dose ICS + LABA
Alt: Medium dose ICS

Step 4: Medium ICS + LABA
Alt: Medium dose ICS + LI, Theophylline or Zileutin

Step 5: High dose ICS + LABA

Step 6: High dose ICS + LABA AND ORAL STEROIDS
What is Daliresp? Dose? SE/contraindication?
Daliresp (Roflumilast) is a phosphodiesterase 4 inh used for COPD.

Dose: 500mcg tabs PO

SE: weight loss, liver impairment
Daliresp drug interactions?
Daliresp (Roflumilast) is a CYP3A4 substrate
Symlin storage?
Unopened vials: Fridge

Opened: Fridge or RT for 28 days
DKA Treatment
1. Hydrate with 0.9% NaCl

2. Give Insulin to transfer sugar from the blood to the cells

3. Give more glucose when levels drop below 250
What are the Oral DM agents?
Sulfonylureas: Glimepiride, Glipizide, Glyburide
Biguanides: Metformin
Thiazolidinediones: Rosiglitazone, Pioglitazone
Alpha-glucosidase inhibitors: Acarbose, Miglitol
Meglitinides: Repaglinide, Nateglinide
Bromocriptine
What is the difference between Dawn Phenomenon and Somogyi Effect?
Somogyi Effect: body gets hypoglycemic (<60) therefore it tries to compensate which results to high glucose levels in the morning

Dawn Phenomenon: happens to everyone when the body releases cortisol, epi and other hormones to help regulate the body which in turn increases glucose levels; if the body doesn't have enough insulin, this results to high glucose levels in the morning
Alpha glucosidase MoA? SE?
Alpha glucosidase: Acarbose & Miglitol

MoA: prevents breakdown of polysacchardies (sucrose) and DELAYS absorption

SE: GI effects & elevated LFT's
Meglitinides MoA? SE?
Meglitinides (Prandin, Starlix) stimulates insulin secretion.

MoA: weight gain & hypoglycemia
What is Tradjenta? Dose? SE?
Tradjenta (Linagliptin) is given 5mg PO QD.

SE: same as other gliptins

Don't give to patients with renal or hepatic impairment.
What is Cycloset? Dose? Max?
Cycloset (Bromocriptine) is a dopamine receptor agonist used for DM.

Dose: 0.8mg tabs given within 2 hrs of waking up in the morning WITH FOOD

Max: 6 tabs
What is Xgeva?
Xgeva (Denosumab) is to prevent skeleta-related events in cancer patients with bone metastases from solid tumors

Form: SC 120mg/1.7mL

Dose (postmenopausal osteoporosis): 60mg Q6 months
Brands for Denosumab?
Xgeva

Prolia
What is Prolia? Dose? Storage?
Prolia (Denosumab)

Dose: 60mg Q6 months

Storage: Fridge, let stand @ RT for 15 minutes prior to use
What is Actemra? Dose?
Actemra (Tocilizumab) is an interleukin-6 receptor inhibitor used for RA

Dose: 4-8mg/kg IV infusion (60 minutes)
Monitoring parameters for Actemra?
Actemra ( Tocilizumab)

Don't start if:
ANC <2000
Platelets <100,000/mm3
ALT/AST >1.5 x ULN
List the Aromatase Inhibitors
***ALE

Anastrozole (Arimidex)
Letrozole (Femara)
Exemestane (Aromasin)
List the Tyrosine Kinase Inhibitors
***NILE - all PO

Nilotinib (Tasigna)
Imatinib (Gleevec)
Lapatanib (Tykerb)
Erlotinib (Tarceva)
List the anti androgens
***No Boy Friend, No Crazy Experience

Nilutamide (Nilandrone)
Biclutamide (Casodex)
Flutamide (Eulixin)
What are the 5-HT3 inhibitors used to treat N/V?
***PDOG

Palodosetron (Aloxi) - IV/PO
Dolasetron (Anzemet) - IV/PO
Ondansetron (Zofran) - IV/PO/IM/ODT
Granisetron (Kytril, Sancuso) - IV/PO/patch
What is Sancuso? Dose?
Granisetron (Kytril, Sancuso)

Dose: 1 patch Q7days, avoid the sun
Name the cannabinoids used for N/V
Marinol (Dronabinol)

Cesamet (Nabilone)
Name the NK1 receptor antagonists used for N/V
Aprepitant - PO

Fosaprepitant (Emend) - IV
Points to remember for Aranesp
Aranesp (Darbepoietin)

1. Don't shake
2. Protect from light
3. Fridge
4. Clear and colorless
Medications used for chemo-induced neutropenia
Filgrastim (G-CSF, Neupogen) given 5mcg/kg/day

Pegfligrastim (Neulesta) given 6mg SC 1x every chemo cycle.
List the Alkylating Agents for Chemo
Cisplatin, Carboplatin, Oxaloplatin
Busulfan
Cyclosphosphamide, Ifosphamide, Temozolomide
Carmustine, Lomustine
Streptozosin
Melphalan, Mechlorethamine, Altretamine
Dacarbazine, Procarbazine
Bendamustine (Treanda)
List the Anti-metabolites for Chemo
Methotrexate
Fluorouracil (5-FU)
Mercaptopurine (6-MP)
Cytarabine, Fludarabine, Capecitabine, Cladribine
Pentostatin
Thioguanine
Hydroxyurea
List the Antibiotics for Chemo
Bleomycin
Dactinomycin
Daunorubicin, Valrubicin, Doxorubicin
Epirubicin, Idarubicin
Mitomycin, Plicamycin
Mitoxantrone
What are the other names for a vertical flow hood?
Type 2 Cabinet

Class 2 Cabinet
What is given with Platinol to prevent nephrotoxicity?
Amifostine is given with Platinol (Cisplatin) to prevent nephrotoxicity.
What is Faslodex? Form? Dose?
Faslodex (fulvestrant) is an estrogen receptor antagonist (HER2)

Form: IM

Dose: slow IM inj in each buttock on days 1, 15, 29 and then Qmonth thereafter.
SE for Faslodex?
Faslodex (fulvestrant)

Bleeding
hepatic impairment
Pregnancy Cat. D
What is Halaven?
Halaven (eribulin) is a microtubule inhibitor for late stage disease chemo