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60 Cards in this Set
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Heparin
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Mech: Binds/activates antithrombin III, increasing protease activity & decreasing thrombin/Xa.
Use: For immediate anticoagulation (short half-life, IV only) in stroke, acute coronary syndrome, MI, DVT, PE. Can use in pregnancy. Monitor PTT. |
Tox: HIT - binds platelet factor IV causing Ab production -> activates platelets -> hypercoagulation, thrombocytopenia (from platelet clearance).
Also, bleeding; osteoporosis; Rx interactions. Protamine - for rapid reversal of action. (+ charge binds heparin) LMWH (Enoxaprin) - inc. bioavailability, action on Xa, & half-life. Dec. HIT & osteoporosis risks; poss. spinal or epidural hematoma. Can use SubQ (outpatient). Not easily reversed. |
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Lepirudin, Bivalirudin.
(Forms of Hirudin) |
Mech: directly bind thrombin (even if bound to fibrin). Originally in leech venom.
Use: By IV for pts with HIT - dec. bad outcomes. |
Tox: bleeding, hepatotox, imm rxn to lepirudin-thrombin complex.
Bivalirudin - transient action (cleaved by thrombin) |
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Argatroban
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Arginine derivative.
Mech: Selective competitive thrombin inhibitor. Monitor aPTT. Use: By IV for pts with HIT - dec. bad outcomes (tho still rather high) |
Tox: bleeding, hematuria
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Warfarin (Coumadin)
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Vitamin K analog.
Mech: blocks γ-carboxylation of coagulation factors by VitK. (KNOW: II, VII, IX, X, proteins C & S). Slow onset & reversal (depends on clearance of profactors). Monitor PT (INR) Use: Oral for clotting disorders (outpatient Tx) |
Tox: bleeding (slow reversal by VitK; fast reversal by frozen plasma). Synergy with heparin
Drug-drug interactions common! 1. If Rx induces P450 → warfarin clearance 2. If Rx binds albumin, warfarin displaced 3. ↑ VitK in diet → ↓ competitive inhibition |
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Dabigatran
Rivaroxaban Ximelagatran |
Mech: direct thrombin or Xa inhibitors
Use: DVT, after hip/knee replacement, atrial fib |
Tox: All depend on liver metabolism.
Ximelagatran - hepatotox! (Not used) Dabigatran - in clinical trials Rivaroxaban - Xa inhibitor |
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Abciximab
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Anti-Platelet
Mech: blocks platelet fibrinogen receptor. Needs to block >90% to fxn. Use: acute coronary syndromes; risk of ischemic event; w/aspirin & heparin during angioplasty |
Tox: bleeding, thrombocytopenia
Monoclonal chimera Ab - Fc is human; Fab is mouse |
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Epifibatide (Integrelin)
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Anti-Platelet
Mech: blocks fibrinogen receptor |
Peptide drug.
SubQ admin. |
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Tirofiban (Aggrastat)
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Anti-Platelet
Similar properties to Abciximab & Epifibatide |
Synthetic version
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Aspirin (ASA)
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Anti-Platelet
Mech: irreversible covalent rxn with COX 1 & COX 2 blocks TXA2 formation, causing dec. platelet activation. Also blocks PGI2 synthesis. Inc. bleeding time, no fx on PT/PTT Use: arterial thrombotic D/Os. Chewable for coronary syndromes & ischemic stroke (dec. infarction & mortality) |
Tox: risk of intracerebral hemorrhage - rare, but serious.
Also: GI ulceration; severe bronchoconstriction and/or hyperventilation; aspirin resistance; tinnitus (CN VIII tox). In kids: Reye's syndrome |
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Clopidogrel (Plavix), Ticlopidine
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Anti-Platelet
Mech: irreversibly blocks platelet ADP receptors. Inhibit fibrinogen binding by preventing glycoprotein IIb/IIIa expression. Use: Transient Ischemic Attacks; unstable angina pectoris; acute coronary syndrome; coronary stenting; dec. incidence/recurrence of thrombotic stroke. If aspirin C/I. |
Tox: Tic - neutropenia.
Clop - more mild (GI upset, rash, etc) |
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Prasugrel
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Anti-Platelet
Mech: Metabolized to active agent by liver. Inhibits ADP-induced platelet aggregation (more rapidly) Use: dec. risk of ischemic events |
Tox: inc. risk major bleeding.
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Ticagrelor
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Anti-Platelet
Mech: reversible antagonist of platelet ADP receptor. Doesn't require metabolism. |
Tox: better M&M than clopidogrel
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Cilastazol
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Anti-Platelet
Mech: Inhibits PDE, elevates cAMP & cGMP, causing vasodilation & inhibited platelet fxn |
Tox: ?
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Streptokinase
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Thrombolytic
Mech: Combines with plasminogen to activate more plasminogen molecules to plasmin. Plasmin speeds breakdown of thrombin & fibrin clots. Use: early MI or ischemic stroke |
Tox: bleeding. Can't differentiate appropriate from inappropriate clots. C/I if: active bleeding, Hx of intracranial bleed, recent surgery, severe HTN.
Treat Tox w/aminocaproic acid (fibrinolysis inhibitor) |
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Urokinase (u-PA)
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Thrombolytic
Mech: Combines with plasminogen to activate more plasminogen molecules to plasmin. Plasmin speeds breakdown of thrombin & fibrin clots. Use: early MI or ischemic stroke |
Human protein = less antigenicity.
Tox: bleeding. Can't differentiate appropriate from inappropriate clots. C/I if: active bleeding, Hx of intracranial bleed, recent surgery, severe HTN. Treat Tox w/aminocaproic acid (fibrinolysis inhibitor) |
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Alteplase (tPA)
Reteplase Tenecteplase |
Thrombolytics
Recombinant Human Tissue Plasminogen Activators Mech: combines with plasminogen, activates plasmin to cause clot lysis. Binds directly to clots; supposedly better selectivity for clot lysis |
Tox: bleeding. Can't differentiate appropriate from inappropriate clots. C/I if: active bleeding, Hx of intracranial bleed, recent surgery, severe HTN.
Treat Tox w/aminocaproic acid (fibrinolysis inhibitor) More expensive, b/c newer. |
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Amicar (Epsilon-Aminocaproic Acid)
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Finbrinolysis Inhibitor
Mech: competitive inhibition of plasminogen & plasminogen activators Use: adjunct for hemophilia Tx. Alleviate bleeding from thrombolytic therapy. Postsurgical GI/prostate bleed. Prophylaxis intracranial aneurysms. Bladder hemorrhage. |
Tox: ?
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Methotrexate (MTX)
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Antimetabolites
Mech: folate analog; inhibits dihydrofolate reductase, causing dec. dTMP & dec. DNA/protein synthesis. S phase specific! Use: leukemias, lymphomas, choriocarcinoma, sarcomas. Breast, head/neck, & lung cancers Non-neoplastic uses: abortion, ectopic pregnancy, rheumatoid arthritis, psoriasis |
Tox: delayed only.
1. Myelosuppression. Reverse with leucovorin rescue (pulse-chase). 2. Macrovesicular fatty changes in liver. 3. Mucositis (GI/oral ulcers) 4. Teratogenic. High affinity - maintains binding when drug withdrawn. |
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5-fluorouracil (5-FU)
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Antimetabolite
Mecvh: pyrimidine analog, activated to 5F-dUMP. Complexes with folate to inhibit thymidylate synthase, causing ↓ dTMP → ↓ DNA & protein synthesis. S phase specific! Use: primary Tx for colon CA. Adjunct for other solid tumors. Topical for basal cell carcinomas. Synergy with MTX. |
Tox: delayed only.
1. Myelosuppression. NOT reversed by leucovorin, but eased by levamisole. 2. Photosensitivity Treat OD with thymidine |
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6-mercaptopurine (6-MP)
6-thioguanine (6-TG) |
Antimetabolites
Mech: purine analogs. Salvage pathway metabolism (HGPRTase) to rNMP. ↓ de novo purine synthesis. Incorporated into DNA, disrupts structure & fxn S phase specific! Use: leukemias, lymphomas (not CLL or Hodgkins). 6MP - pediatric leukemia 6TG - adult leukemia, ALL |
Tox: myelosupp; hepatotox; immunosupp
6MP - ↑ tox w/allopurinol (C/I) b/c metabolized by xanthine oxidase. 6TG - no fx with allopurinol |
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Cytarabine (ara-C)
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Antimetabolite
Mech: pyrimidine antagonist. - Competitive inhibition of dCTP, incorporated into DNA - Inhibits DNA Pol & chain elongation - Inhibit Osaki fragment ligation S phase specific! Use: in combination chemo. AML; acute myelomonocytic leukemia; ALL; high-grade non-Hodgkins |
Tox - delayed only. SEVERE myelosupp. -> thrombocytopenia, leukopenia, megaloblastic anemia
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Capecitabine
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Antimetabolite
Mech: liver metabolism to intermediate. Tumor cell metabolism to 5-FIUra. Salvage pathway metabolism to 5-FU. (See 5-fluorouracil card) Use: primary for breast CA, or in combo with docetaxal. Adjunct for stage III colon CA Alone for metastatic colon CA |
Tox: hand-foot syndrome - redness & blistering on palms/soles.
Slight myelosupp & N/V |
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Dactinomycin (Actinomycin D)
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Antitumor Abx
Mech: intercalate C-G base pairs, cause ssDNA breaks. VERY potent! Use: childhood tumors - Wilms, Ewing's, rhabdomyosarcoma. (Kids ACT up - ACTinomycin) |
Tox: hemopoietic suppression
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Doxorubicin (epirubicin)
Daunorubicin (idarubicin) |
Antitumor Abx - Anthracyclines
Mech: intercalates into DNA, causes breaks. Free radical generation from rxn with O2 (catalyzed by P450 reductase). Use: Doxo - Hodgkins, myelomas, sarcomas, BREAST/ovary/lung Dauno - ALL, AML |
Tox: cardiotox! Inc. resting HR, CHF, arrhythmia, myopathy
Also - red pee! Myelosupp, alopecia. |
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Bleomycin
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Antitumor Abx
Mech: forms free radicals, causes ss & dsDNA breaks. Intercalates w/DNA to cause breaks. G2 phase specific! Use: squamous carcinomas - cervix, head/neck, lungs. Hodgkins lymphomas, testicular tumors. |
Tox: PULM FIBROSIS!
minimal myelosupp - can be used in combo chemo b/c toxicities don't overlap with other drugs! Mnemonic - "G! My lungs are 2 FIBROSED to BLEO [blow]!" |
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Etoposide (VP-16)
Teniposide |
Antitumor Abx
Mech: inhibits topoisomerase II; causes DNA degradation. Use: small cell carcinomas - lung, prostate Testicular carcinoma |
Tox: myelosupp., alopecia
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Streptozocin (ST2)
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Antitumor Abx
Mech: methylnitrosourea on glucose 2C Use: high affinity for pancreatic islet cells |
Tox: nephrotox! (dose-limiting)
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Mitomycin
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Antitumor Abx
Mech: reduced to alkylating agent. Cross-links DNA. Works best in hypoxic tumor stem cells in solid tumors (most sensitive condition) Use: *best* in combo with radiation for hypoxic tumor cells. Sq cell carcinoma - anus, cervix Adenocarcinoma - stomach, pancreas, lung Superficial bladder cancer |
Tox: myelosuppression. Thrombocytopenia, anemia, leukopenia
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Mitoxantrone (DHAD)
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Antitumor Abx
Mech: bind DNA, causes breaks. Inhibit DNA/RNA synthesis. Use: adv. hormone-refractory prostate cancers. Low-grade non-Hodgkins. Acute myeloid leukemias, breast cancer. |
Tox: blue color to nails, sclera, & urine!
Cardiac tox. The usual: myelosupp, N/V, alopecia, mucositis |
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Cyclophosphamide (CTX)
Ifosfamide |
Alkylating Agents
Mech: Activation by CYP 2C19. Transfer alkyl to guanine N7; base pair mismatch or guanine excision causes cell death. Use: CTX - broad; esp. non-Hodg. Also for autoimm dz. Ifo - germ cell testicular cancers, sarcomas |
Tox: myelosupp (dose-limiting!)
Immunosupp. (can also be indication) Hemorrhagic cystitis (lessen with mesna) SIADH |
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Nitrosoureas
- BCNU (Cormustine) - CCNU (Lomustine) - methyl-CCNU (Semustine) - Streptozocin |
Alkylating Agents
Mech: bioactivation. V. lipophilic, crosses BBB. Alkylates DNA at guanine O6. Best fx in plateau phase (not exponential growth) Use: brain tumors, GI neoplasms |
Tox: myelosupp (cumulative, dose-limiting!)
High cardiogenic, mutagenic Renal failure in long-term use |
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Busulfan
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Alkylating Agents
Mech: Alkylates. (See others) Use: CML. Chronic granulocytic leukemia. Marrow ablation (before BMT) |
Tox: myelosupp., prolonged thrombocytopenia.
Teratogen, nephrotox (dec. with allopurinol). Cataracts, gynecomastia. Pulmonary fibrosis, hyperpigmentation. |
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Thiotepa
Altretamine |
Alkylating Agents (Aziridines)
Mech: Alkylate DNA -> cell death. Alt - demethylated in liver. Use: refractory cancer - WHEN FIRST-LINE DRUGS FAIL! Adv ovarian, breast, bladder cancers lymphoma, rhabdomyosarcoma |
Tox: Thio - myelosupp., mucositis
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Mechlorethamine
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Alkylating Agents (Nitrogen Mustard)
Mech: alkylate DNA at guanine N7 - Abnormal base pairing - Base excision - Cross-linking Most reactive N mustard; rarely used anymore. Use: in combo chemo for Hodgkins |
Tox: leukopenia & thrombocytopenia are dose-limiting!
Lacrimation. |
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Chlorambucil
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Alkylating Agents (Nitrogen Mustard)
Mech: DNA alkylation at guanine N7; causes mispairing, excision, cross-linking. * Slowest-acting N Mustard used clinically Use: first-line for CLL, MM, & Waldenstrom's macroglobulinemia |
Tox: low. Able to give chronically in CLL (mos to yrs)
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Melphalan
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Alkylating Agent (Nitrogen Mustard)
Mech: alkylates DNA. Phenylalanine derivative. Use: oral, for multiple myeloma |
Tox: NOT a vesicant (like other alkylating agents).
Hematological fx. No alopecia, little N/V |
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Procarbazine
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Alkylating Agent (probably)
Mech: Metabolic activation; methylates DNA. Causes chromatid breaks & translocations Use: In combo chemo for Hodgkins ALWAYS in combo |
Tox: secondary tumors - HIGH risk!
Potent immunosupp. Mutagenic, teratogenic |
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Cisplatin
Carboplatin Oxaliplatin |
Platinum Analogs
Mech: cross-link DNA to inhibit replication & transcription; causes breaks & miscoding. Use: broad; for solid tumors. Curative for adv testicular cancer Tx for ovarian, head/neck, bladder, esophagus, & lung |
Tox: Nephrotox!! Avoid with hydration & diuresis
Peripheral neuropathy Severe alopecia Marrow tox, cystitis, ototox. |
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Vincristine
Vinblastine |
Microtubule Inhibitors (Antimitotic)
Mech: binds tubulin dimers & blocks phosphorylation of tubulin. M phase specific! Use: IV. Vinblas - systemic Hodgkins Vincris - combo chemo w/prednisone for kids' acute leukemia |
Tox: Vinblas - acute N/V
Vinblas - delayed marrow tox, alopecia Vincris - delayed only. Neurotox! Both - peripheral neuropathy |
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Palcitaxel
Docetaxel |
Microtubule Inhibitors (Antimitotic)
Mech: hyperstabilizes polymerized tubulin; can't enter anaphase. M phase specific Use: Pal - ovarian (not great results), adv breast CA Doc - breast, ovarian, non-small cell |
Tox: Pal - acute N/V, hypotension, arrhythmia. Delayed marrow supp.
Doc - delayed alopecia, hematological fx. Both - peripheral neuropathy |
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Dexamethasone
Prednisone |
Adrenocorticosteroid (Glucocorticoid)
Mech: Lymphocytic. Binds cytoplasmic receptor → gene expression → apoptosis. ↓ lymphocyte mitosis. May even work on non-dividing cells. Use: ALL, CLL, MM, Hodg (MOPP regimen) & non-Hodg, adv. breast CA. "Other hematologic malignancies." Also used as immunosuppressant for autoimmune dz. |
Tox: glucose intolerance (hyperglycemia), imm.supp., osteoporosis, GI ulcers, psychosis.
Cushing-like Sx, HTN, catarcts, acne. |
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Hydroxyurea
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Mech: Inhibits Ribonucleotide Reductase, → ↓ DNA synthesis.
S phase specific! Use: Melanoma, CML, SCD (↑ HbF). |
Tox: myelosupp., GI upset.
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Tamoxifen
Raloxifen |
Anti-estrogens (SERMs)
Mech: estrogen receptor ligand - antagonist in breast, agonist in bone. Competitive inhibitor of ER. Blocks binding of ERE (estrogen-responsive element) on DNA. ↓ IGF-1 production (paracrine growth factor). Use: ER+ breast cancers. Also prevents osteoporosis. |
Tox: ↑ risk of endometrial carcinoma (rare). Hot flashes, N/V (acute). Clotting abnormalities.
Raloxifene - no inc. risk of endometrial CA (endometrial antagonist). |
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Flutamine (Bicalutamide)
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NSAAs - non-steroidal antiandrogens
Mech: inhibit translocation of androgen receptor to nucleus (thereby dec. androgen fx). Prevent natural ligand binding to androgen receptor. Use: prostate cancer. |
Tox: diarrhea, emesis, hot flashes, loss of sex fxn. Reversible liver abnormalities, gynecomastia, mastodynia.
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Leuprolide
Goserelin |
GnRH & LHRH analogs (respectively)
Mech: biphasic fx on pituitary: initial stimulation of FSH & LH; later desensitization, inhibited FSH & LH. [Testerone] ↓ → castration levels. [Estrogen] ↓ → postmenopausal values. Use: prostate carcinoma. Add'l hormone manipulation for breast CA in pre-menopausal women. |
Tox: secondary to ↓ sex steroids. Hot flashes, sweating, N, fatigue, ↓ bone/muscle mass, bone pain, hematuria.
Men: testicular atrophy, gynecomastia, impotence Women: vag. bleeding, amenorrhea |
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Aminoglutethimide
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Aromatase Inhibitor
Mech: Blocks cholesterol conversion to pregnenolone; blocks androgen conversion to estrogens. Thereby inhibits adrenocortical steroid synthesis. Use: advanced carcinoma when tumor contains estrogen receptors. Adrenocortical carcinoma w/Cushing's. Metastatic, hormone-dependent breast CA (refractory to other hormone Tx) |
Tox: blurred vision, ataxia, skin rash, lethargy, drowsiness.
Combo chemo for breast cancer: Leuprolide + Goserelin + Tamoxifen + Aromatase Inhibitor |
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Asparaginase (L-Asparaginase)
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Enzyme Inhibitor
Mech: catalyzes hydrolysis of circulating asparagines; deprives tumor of asparagines needed for protein synthesis. Cell Cycle Specific - best in G1 Use: in combo chemo for ALL |
Tox: from antigenicity & protein synthesis inhibition.
Clotting abnormalities, hyperglycemia, acute hypersens., hepatotox, GI tox |
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Imatinib
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-nib = kiNase InhiBitor
Mech: Inhibit CML-specific signal transduction. Inhibits TK domain of Bcr-Abl protein, preventing phosphorylation of kinase substrate. Specific for Phila chromosome Use: first-line - chronic & blast phases of CML. Second-line - chronic phase CML after IFN-alpha Tx Also for GIST - if expressing c-kit TK. |
Tox: NV, myalgia, edema
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Topotecan
Irinotecan |
Camptothecins
Mech: inhibit topoisomerase I, blocking transcription/replication. Irinotecan activated (to SN-38) in liver by carboxylesterase. Use: Topo - adv. ovarian cancer after platinum drugs fail. Small cell lung cancer. Irino - second-line monotherapy in metastatic colorectal after 5FU fails. First-line - in combo with 5FU & leucovorin |
Tox: myelosupp., diarrhea
Top - excreted renally; caution if abnormal renal fxn. Irin - eliminated by bile/feces; reduce dose if liver dysfxn. |
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All-trans-Retinoic acid (ATRA, tretinoin)
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Mech:specific for t(15;17) translocation in APL (acute promyelocytic leukemia). Translocation fuses VitA receptor alpha to PML gene. ATRA binds PML/RAR-alpha.
Use: APL, especially if relapsed after anthracycline-based chemo (or if anthracycline C/I). |
Tox: related to VitA toxicity.
H/A, fever, dry skin/mucosa, rash, pruritus, conjunctivitis. CNS tox - dizziness, anxiety, depression, confusion, agitation. Teratogenic! |
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Arsenic trioxide (AS2O3)
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Mech: induce degradation of PML/RAR-alpha made by t(15;17) translocation. Induce apoptosis through cytochrome C release & caspase activation.
Use: APL, esp. if refractory or relapsed after ATRA & anthracycline |
Tox: fatigue, QT prolongation, arrhythmia.
Syndrome - fever, dyspnea, rash, fluid retention, weight gain. |
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Cetuximab
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Monoclonal Ab
Mech: binds extracellular domain of EGFR (epidermal growth factor receptor). EGFR signaling pathway triggers growth/proliferation, invasion/mets, angiogenesis. Use: combo w/irinotecan if refractory first-line for metastatic colorectal CA combo w/radiation in locally adv head & neck CA |
Tox: mild. Acneiform rash, hypersensitivity
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Gefitinib
Erlotinib |
kiNase InhiBitors
Mech: inhibit TK domain assoc w/EGFR. Use: non-small cell lung CA (refractory to prior Tx) Adv pancreatic CA Non-smokers with lung cancer (bronchoalveolar histo) |
Tox: Acneiform rash, diarrhea
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Trastuzumab
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Monoclonal Ab (IgG)
Mech: against HER2 (type 2 EGFR), overexpressed in breast CAs (25-30%). HER2 assoc w/aggressive dz. Cytotoxicity arrests cell cycle. Use: combo w/paclitaxel HER2+ metastatic breast CAs. After first-line Tx fails |
Tox: diarrhea, hematologic fx
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Bevacizumab (Avastin)
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Recombinant Humanized Monoclonal Ab
Mech: binds all VEGF-A forms & prevents interaction with VEGF receptors Use: combo chemo for met. colorectal CA. First-line for metastatic colorectal |
Tox: HTN, inc. arterial thromboembolic events, trouble w/wound healing, GI perforations, proteinuria
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Rituximab
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Chimeric Monoclonal Ab (IgG)
Mech: binds CD20 antigen which is overexpressed on B cells of non-Hodgkins. Ab binding causes cell lysis (either Ab-dependent cytotoxicity or complement). Use: relapsed non-Hodg (R-CHOP regimen) |
Tox: usu dermatologic & GI.
CV - angina Resp - obliterative bronchiolitis |
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Bortezomib
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-mib = Molecule InhiBitor
Mech: inhibit proteasomal pathway, ↓ intracellular protein degradation. ↓ proliferation & mets. Use: MM (as 2nd therapy) Mantle cell lymphoma |
Tox: GI common.
Poss. peripheral neuropathy |
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GM-CSF - Granulocyte-Macrophage Colony Stimulating Factor. Sargramostim
G-CSF - Granulocyte Colony Stimulating Factor. Filgrastim |
Bone marrow growth factors
Mech: bind specific receptors on target cells to stimulate granulocyte proliferation (neutrophils, monocytes, eosinophils, basophils). Use: Dec. risk of infxn & sepsis. Shorten hospitalization after BMT. |
G-CSF tox - better than GM-CSF. Bone pain, splenic rupture (rare).
GM-CSF tox - fever, malaise, arthralgia, myalgia, capillary leak syndrome, allergy. |
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Darbopoetin-α
Erythropoietin (EPO) |
Chemo Adjunct
Mech: bind receptors → ↑ RBC progenitor proliferation & differentiation. Use: to ↓ chemo-induced anemia or anemia assoc w/chronic renal failure |
Tox: rapid ↑ in Hb & Hct; HTN; thrombosis; allergy.
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Amifostine
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Thiophosphate analog
Mech: activated by membrane-bound alkaline phosphatase to WR-1065. Scavenger for free radicals & superoxide; inactivate ROS from cisplatin & radiation. Use: ↓ nephrotoxicity from cisplatin in ovarian & non-small cell lung cancers. ↓ xerostomia after radiation in head/neck cancers. ↓ pneumonitis & esophagitis from chemo. ↑ marrow growth in myelodysplastic syndrome. |
Tox: ?
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