ONCOLOGY (26-40)
ulcerations, Behcet’s disease
1. Antithymocyte globulin (ATG) is the
treatment for aplastic anemia. When
the question describes pancytopenia of
unclear etiology, and a bone marrow
transplant is not possible, then the
answer is ATG. ATG is used to treat
aplastic anemia in combination with
cyclosporine for those unable to
undergo transplantation. ATG can also
be used to prevent graft versus host
disease and prevent renal transplant
rejection.
2. ATG works by removing cytotoxic T
lymphocytes. From circulation. This
allows the bone marrow to regrow
3. ATG can cause serum sicknesss, rash,
anaphylaxis, thrombocytopenia and
myalgias.
Azacytidine
-What condition does this medication treat?
-how does azacytidine work?
What are the common adverse effects of
azacytidine?
1. Azacytidine is a treatment for
myelodysplastic syndrome. An older
patient with anemia, elevated MCV and
a small percentage of blasts calls for
azacytidine as the answer.
2. Azacytidine works by incorporating
itself into RNA and DNA. And inhibiting
methylation of DNA. It is a pyrimidine
nucleoside analog cytidine. It is directly
cytotoxic to abnormal bone marrow
hematopoietic cells.
3. Major toxicities: myelosuppression and
severe nausea and vomiting
Thalidomide
-what disease is treated with thalidomide?
-How does it work?
-Common adverse effects?
1. Thalidomide has an effect in the
treatment of multiple myeloma.
Other uses: leprosy, aphthous
2. Anti-inflammatory effects: inhibition of
tumor necrosis factor and angiogenesis
3. Teratogenic; peripheral neuropathy,
sedation, dry mouth and skin
Cladribine and entostatin
-when do you answer cladribine or
pentostatin?
-how do these medications work?
-Common adverse effects?
Case: a 67-year old man is evaluated for a
markedly elevated WBC count of 85000 of
which 90% are normal appearing lymphocytes.
“Smudge cells are visible on smear. He has
anemia, thrombocytopenia and an enlarged
spleen.
-what is the best therapy?
-how does this treatment work?
-what are the common adverse effects of
this therapy?
1. Fludarabine is the best therapy for
advanced stage chronic lymphocytic
leukemia (CLL). Presence of anemia,
thrombocytopenia and splenomegaly
indicate that this is the advanced stage.
It can be combined with
cyclophosphamide or rituximab.
Chlorambucil is used only as palliative
to decrease the white cell burden of
older patients.
2. It works by interfering with DNA
synthesis and DNA repair through
inhibition of DNA polymerase.
Chlorambucil’s metabolite phenylacetic
mustard is pharmacologically active
against CLL.
3. Both Fludarabine and Chlorambucil
cause myelosuppression.
Card 11
1. Cyclophosphamide is an alkylating
agent that is widely used as an
 immunosuppressive and cancer
therapeutic.
2. It works by cross-linking DNA. This
“breaks” the DNA and broken DNA
cannot participate in cell division
and reproduction. Instead, it is
metabolized to acrolein.
3. Cyclophosphamide can cause
hemorrhagic cystitis from the
acrolein.
4. Cyclophosphamide can be used in
the following conditions:
-Acute leukemia and lymphoma,
retinoblastoma and a wide variety
of cancers
-Wegener’s granulomatosis
-Polyarteritis nodosa
-Lupus nephritis
-Nephrotic syndrome
-Rheumatoid arthritis
CYCLOSPORINE
-what is cyclosporine?
-how does it work?
-what are cyclosporine’s most common
adverse effects?
-when is cyclosporine the answer?
1. Cyclosporine is a T cell-inhibiting
immunosuppressive agent that is
used to prevent organ transplant
rejection and to control
autoimmune diseases not
responsive to other initial therapy.
2. Cyclosporine inhibits calcineurin.
3. Most common adverse effect is
neurotoxicity. There is increased
susceptibility to fungal and viral
infections.
4. Cyclosporine is the best initial
therapy for the following
conditions: organ transplant
rejection, aplastic anemia, to
prevent graft versus host disease.
5. Second-line therapy to treat
rheumatoid arthritis, ulcerative
colitis, Behcet’s syndrome and
psoriasis. It is used to treat
myasthenia gravis to spare the
patient from chronic steroid use.
Case: A 74-year old woman with breast cancer
presents with back pain. She has spinal
tenderness, hyperreflexia of the lower
extremities and decreased sensation below her
umbilicus extending through the lower half of
her body.
What is the next best step in the management
of this patient?
1. Steroid administration is the most
important action in patients with an acute
cord compression. The patient has back
pain, tenderness and hyperreflexia. The
most important thing is to relieve the
pressure on the spinal cord with steroids.
Steroids decrease the edema surrounding
the tumor. MRI is the most accurate test for
compression but not as important as
steroids.
Case: A 37-year old woman comes to see
you for evaluation of breast cancer. Her
mother and sister both had breast cancer
before the age of 45. Her mammogram is
normal.
-What is the best therapy for this patient?
-Mechanism of action?
-most common adverse effects?
1. Tamoxifen should be recommended for
patients at high risk of breast cancer.
Patients with two or more first degree
relatives with breast cancer have a
markedly increased risk of breast
cancer-somewhere four to six times
higher than average. Tamoxifen
decreases the risk of breast cancer for
these patients.
2. Tamoxifen and raloxifene act as
estrogen receptor agonists or
antagonists depending on the tissue.
They are estrogen receptor antagonists
on breast tissue. This is the basis of
their efficacy in treating breast cancer.
They are estrogen agonists on the
 bones and liver. This is the basis of the trabeculoplasty or iridotomy is
beneficial effects of Raloxifene on performed.
osteoporosis. Tamoxifen is an agonist in
the uterus, raloxifene is not.
3. Tamoxifen can lead to thromboembolic Case: two patients present with progressive loss
disease, endometrial cancer, menstrual of vision. Both are older and generally health,
irregularities, sexual dysfunction and without diabetes or hypertension. One has
hot flashes. atrophic or “dry” macular degeneration with
multiple drusen visible. The other has “wet”
OPHTHALMOLOGY proliferative disease.
Case: a 70-year old woman comes to the -What is the therapy for each patient?
emergency department with sudden onset
of a painful, red eye. The cornea is hazy and 1. Dry or atrophic macular degeneration
edematous. The pupil is fixed at the has no proven effective therapy. Laser
midpoint and nonreactive. Visual acuity is therapy does not help, and the disease
decreased. will progress slowly over time.
-what are the best initial medical Antioxidant vitamins such as vitamins
treatments? A, C and E as well as Zinc may offer
-how do these treatments work? some benefit.
-what is the treatment if medical therapy 2. Wet or proliferative macular
fails? degeneration has more therapeutic
options. Treatment with VEG-F
1. Acute closed-angle glaucoma is treated inhibitors such as ranibizumab,
with medications to increase the bevacizumab or pegaptinib. Laser
drainage of aqueous humor and to photocoagulation can be useful.
decrease the production of aqueous
humor. Timolol and Pilocarpine drops PSYCHIATRY
are the best initial therapy. They
constrict the pupil. Risperidone
2. Mechanism: -what question is risperidone the answer
-beta blockers (timolol and betaxolol) -how does risperidone work?
constrict the pupil and increase both -most common adverse effects?
the drainage of fluid and inflow.
-Cholinergic agonists (pilocarpine) 1. Treatment for chronic schizophrenia.
increase drainage of the aqueous 2. Mechanism is unknown. It has an
humor by opening the canal of affinity for antagonizing both serotonin
Schlemm and dopamine receptors.
-carbonic anhydrase inhibitors 3. Can cause: weakness, sedation,
(acetazolamide, dorzolamide) decrease difficulty concentration and
the production of aqueous humor hypotension, elevated prolactin levels,
-alpha adrenergic agonists sexual dysfunction and tardive
(apraclonidine, brimonidine) increase dyskinesia.
drainage
-prostaglandin analogs (latanoprost or Olanzapine, Ziprasidone, Quetiapine,
travaprost) increase drainage Aripiprazole, Clozapine and Risperidone

3. If medical therapy does not control -what are the medications?

does not control ocular pressure, laser -how do they work?
-common adverse effects? -why is it the answer?

1. These medications are second 1. Lithium is an alkali metal that can treat
generation or atypical antipsychotics. symptoms of mood disorders. Proposed
Clozapine is the most efficacious but mechanism may be through
has the highest incidence of side effects suppression of inositol triphosphate.
such as agranulocytosis. 2. Adverse effects: tremor, ataxia,
2. Precise mechanism is unknown. Bind to seizures, nephrogenic diabetes insipidus
serotonin, dopamine, alpha or through inhibition of ADH receptor,
histamine receptors. hypothyroidism by inhibiting
3. Cause hypotension, somnolence, weight thyroglobulin iodination and coupling,
gain, prolong QT interval, tardive teratogenesis causing Ebstein’s
dyskinesia, prolactin elevation and anomaly.
myelosupression. 3. Indicated for bipolar disorder and acute
mania. Prophylactic against migraine
SELECTIVE SEROTONIN REUPTAKE and cluster headaches.
INHIBITORS (SSRI)
Fluoxetine, Paroxetine, Sertraline,
Fluvoxamine, Escitalopram
-what are SSRIs?
-how do they work?
-when are SSRIs the answer?
-common adverse effects?

Case: A 32-year old woman comes to the

emergency department because of the
acute onset of facial grimacing, torticollis,
oculogyric crisis and abnormal contractions
of spinal muscles. She has just started on
antipsychotic medications fluphenazine as
well as metoclopramide for nausea.
-diagnosis?
-how did this happen?
-best initial therapy?

1. The patient has an acute dystonic

reaction from antipsychotic
medications and metoclopramide.
2. Precise mechanism is unclear. Occurs
because of antidopaminergic reactions
of antipsychotics and metoclopramide.
3. Treated effectively with
diphenhydramine and benztropine.

LITHIUM

-MOA?
-adverse effects?